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LATERAL  CURVATURE  OF  THE  SPINE 


AND 


ROUND  SHOULDERS. 


LOVETT, 


V 


LATERAL  CURVATURE  OF 
THE  SPINE 


AND 


ROUND  SHOULDERS 


BY 

ROBERT    W.   LOVETT,   M.D. 

BOSTON 

ASSOCIATE    SURGEON    TO    THE   CHILDREN'S    HOSPITAL,    BOSTCiN  ;     SURGEON   TO    THE   INFANTS* 

HOSPITAL  ;    INSTRUCTOR   IN  ORTHOPEDIC   SURGERY,   HARVARP   MEDICAL   SCHOOL  ; 

MEMBER     OF     THE     AMERICAN     ORTHOPEDIC     ASSOCIATION;      KORRE- 

SPONDIERENDE     MITGLIEDER      DER      DEUTSCHEN      (iESKLL- 

SCHAFT    FUR    ORTHOPADISCHE    CHIRURGIE 


Mitb  154  1fllu0tration6 


PHILADELPHIA 

P.    BLAKISTON'S   SON   &    CO 

IOI2  Walnut  Street 
1907 


TJ>^7/ 

L^f 

C0P\TJIGHT,   1907,  BY  P.  BlAKISTON'S  SOX    &  CO. 


GfROF 
TEACHERS  COLLEee 


PRESS     OF 

WM.     F.     FELL    COMPANY 

1220-24   Sansom    Street 

philadelphia,    pa. 


TO 

ALBERT    HOFFA 

BERLIN 
AS  A  TOKEN  OF  FRIENDSHIP  AND  RESPECT 


PREFACE. 


The  successful  treatment  of  lateral  curvature  of  the  spine  cannot  in 
the  past  be  counted  as  one  of  the  achievements  of  orthopedic  surgery. 
The  affection  is  not  only  intrinsically  resistant  to  treatment  but  the  thera- 
peutic measures  employed  have  been  on  the  whole  largely  empirical  and 
have  not  been  sufficiently  correlated  to  its  pathology  and  to  the  mech- 
anism by  which  it  is  caused.  In  the  last  ten  years,  however,  a  good 
deal  of  progress  has  been  made  along  new  and  promising  lines,  by  means 
of  experimental  and  clinical  work,  the  records  of  which  lie  scattered 
through  later  medical  literature.  In  the  following  pages  I  have  at- 
tempted to  bring  together  this  literature  and  to  add  my  own  personal 
views  and  experience,  in  the  hope  of  presenting  the  subject  in  English 
in  a  modern  light  and  to  call  attention  to  the  prospect  offered  of  obtain- 
ing better  results.  That  such  a  book  is  needed  I  have  been  led  to  infer 
from  many  inquiries  in  connection  with  this  subject  by  physicians, 
medical  students,  and  teachers  of  physical  training.  If  I  have  devoted 
too  large  a  part  of  the  book  to  the  question  of  treatment  it  is  because  of 
the  scant  attention  paid  to  that  part  of  the  subject  in  most  books  dealing 
with  deformities. 

The  anatomical  part  of  the  work  is  from  the  Anatomical  Department 
of  Harvard  University,  and  much  of  the  clinical  work  is  from  the  Scoliosis 
Clinic  of  the  Children's  Hospital,  Boston. 

It  is  impossible  to  acknowledge  my  indebtedness  individually  to 
those  of  my  colleagues  and  others  who  have  helped  me  by  contributing 
material  and  other  assistance.  I  should,  however,  express  my  obligation 
to  Professor  Thomas  Dwight  for  his  advice  given  in  connection  with  the 
anatomical  part  of  my  work,  for  the  liberal  supply  of  anatomical  material 
with  which  he  has  provided  me,  and  for  criticising  my  chapter  on  x\natomy. 
To  Miss  Amy  Morris  Homans,  Director  of  the  Boston  Normal  School 
of  Gymnastics,  I  wish  to  express  my  indebtedness  for  assistance  given 
in  many  ways;  and  to  my  assistants,  Fraiilein  Helene  Seltmann  and 
Miss  W.  G.  Wright,  for  great  help  in  preparing  the  list  of  exercises. 

I  have  used  freely  the  chapters  on  Pathology  and  Occurrence  in  the 
admirable  article  on  Scoliosis  by  Schulthess  of  Ziirich,  recently  pub- 
lished in  Joachimsthal's  "  Handbuch  der  Orthopadischen  Chirurgie." 

Robert  W.  Lo\ett. 
BosTO.v,  1907. 


TABLE  OF  CONTENTS. 


CHAPTER  PAGE 

j/*^-  The  Anatomy  of  the  Vertebral  Column  and  the  Thorax i 

•  II.  The  Movements  of  the  Spine 23 

III.  The  Mechanism  of  Scoliosis 38 

IV.  Description  and  Symptoms 46 

V.  Examination  and  Record  of  Scoliosis 64 

j>^I.  Pathology 77 

"-  VII.  Etiology — Influence  of  School   Conditions. 91 

VIII.  Occurrence ' loS 

/IX.  Di.\GNOSis : ; 113 

/  /X.  Prognosis 116 

/  XI.  Treatment 118 

II.  Faulty-  Attitude 167 


^' 


*■ 


LATERAL  CURVATURE  OF  THE  SPINE  AND 
ROUND  SHOULDERS. 

Chapter  I. 

ANATOMY  OF  THE  VERTEBRAL  COLUMN  AND 
THE  THORAX. 

The  spine  is  a  flexible  weight-bearing  column  made  up  of  a  series 
of  vertebrae  separated  from  each  other  by  twenty-three  intervertebral 
discs  and  connected  with  each  other  by  ligaments  and  muscles.  In 
early  life  the  vertebrae  are  thirty-three  in  number.  The  upper  twenty- 
four,  remaining  separate  throughout  life,  are  distinguished  as  true, 
movable,  or  presacral  vertebrae.  In  the  adult  the  lower  nine  are  fused 
into  two  masses  to  form  the  sacrum  and  the  coccyx,  and  are  called  the 
false,  fixed,  or  immovable  vertebrae.  The  spine  forms  the  central  axis 
of  the  skeleton,  situated  in  the  median  plane  of  the  body  and  posterior 
part  of  the  trunk.  By  the  term  "the  spine"  is  generally  understood 
the  part  of  the  column  above  the  sacrum. 

In  shape  the  spinal  column  is  roughly  pyramidal,  the  column  of  verte- 
bral bodies  tapering  from  beloAv  upward,  and  after  early  infancy  it  shows 
four  curves,  two  anterior  and  two  posterior,  in  the  sagittal  or  median 
anteroposterior  plane.     These  are  called  the  physiological  curves. 

The  column  is  supported  in  unstable  equilibrium  on  the  sacrum. 
It  receives  the  weight  of  the  arms,  the  head,  and  the  thorax,  and  their 
contents,  which  it  transmits  through  the  sacro-iliac  joints  to  the  pelvis 
and  thence  through  the  legs  to  the  ground.  The  spine  encloses  and 
protects  the  spinal  cord,  and  provides,  with  the  sacrum,  thirty-one 
pairs  of  intervertebral  foramina  through  which  the  spinal  nerves  emerge. 
It  serves  by  its  intervertebral  discs  to  diminish  the  jar  of  walking. 

The  total  length  of  the  spine  is  given  as  follows  by  different  authors: 
Cunningham,  70  to  73  cm.;  Morris,  70  cm.;  and  Krause,  72  to  75  cm. 
(along  the  curves),  which  is  45  per  cent,  of  the  body-length.  The 
relative  length  of  the  separate  regions  is  shown  in  the  following  table: 

Cunningham. 1        Morris.-  Beaunois.  Dwight.s 

Males.  Females. 

Cervical  region 13-140111.         12.5  cm.         10.8  cm.         13.3  cm.         12.1cm. 

Dorsal  region 27-29  cm.         27.5  cm.         27     cm.         28.7  cm.         26.5  cm. 

Lumbar  region 12-15  cm.         17.5  cm.         16.8  cm.         19.9  cm.         1S.7  cm. 

^  Cunningham:  "Text-book  of  Anatomy,"  Macmillan,  1902. 
^Morris:    "Human  Anatomy,"  Blakiston,  1903. 
^  Dwight:   "Medical  Record,"  Sept.  S,  1S94. 


2  ANATOMY   OF   VERTEBRAL   COLUMN   AND   THORAX. 

It  is  frequently  stated  that  the  length  of  the  spine  in  different  individuals 
is  pretty  constant,  but  Dwight's  figures  show  rather  a  wide  variation. 
In  fifty-six  male  spines  the  longest  was  69.8  cm.  and  the  shortest  56.4 
cm. 

In  a  straight  line,  the  column  measures  in  men  from  66  to  70  cm., 


£..  ;»^ 


Fig.  I.— The  Spine  Seen  from  the 
Side,  Showing  the  Physiological 
Curves. — ( IFarreji  Museum.) 


Fig.    2. 


Thk    Sf'iNi      Si;en    from    the 
Front. — (  Warren  Museum.) 


and  in  women  from  66  to  69  cm.,  with  an  average  of  67  cm.  (Krause). 
The  height  along  the  chord  of  this  arc  is  forty  per  cent,  of  the  total 
height  of  the^ndividual.     In  the  fetus  and  young  child  the  column  forms  1/ 
a  greater  proportion  of  the  body-length.     At  puberty  the  more  rapid 
growth  of  the  rest  of  the  body  overtakes  that  of  the  spine,  which 


INTERVERTEBRAL   DISCS.  3 

completes  its  growth  between  the  ages  of  twenty-three  and  thirty-one 
years. 

The  percentage  of  total  length  of  the  individual  occupied  by  the 
spine  without  the  sacrum  is  given  for  different  ages  by  Moser  as  follows: 

Per  Gent,  of  Verte- 
Vertebral  Column       bral  Column  to 
Body-length.  Length.  Body-length. 

o 50  19-2  38-4 

3 86  31.7  36-8 

5 112  35  30 

II 138  41  29.7 

14 152  44  28.9 

15^ 162  45  28.1 

Adult 167  57  34.1 

The  spine  is  divided  into  three  regions  corresponding  to  the  parts 
of  the  trunk  with  which  it  is  connected:  (i)  The  cervical  region;  (2) 
the  thoracic  or  dorsal  region;   (3)  the  lumbar  region. 

The  cervical  region  comprises  the  upper  seven  vertebras,  including 
the  atlas  and  axis;  the  thoracic,  twelve  vertebrae;  and  the  lumbar, 
five  vertebrae.  The  lower  part  of  the  spine  may  be  spoken  of  as  the 
posterior  end,  while,  the  upper  part  may  be  called  the  anterior  end  of 
the  column.  The  middle  of  the  spine  is  placed  at  the  eleventh  dorsal 
vertebra. 

The  line  of  gravity  in  the  upright  position  passes  through  the  bodies 
of  the  second  and  twelfth  dorsal  vertebras,  and  touches  the  lower  ante- 
rior border  of  the  last  lumbar  vertebra. 

INTERVERTEBRAL  DISCS. 
The  bodies  of  the  vertebrae,  from  the  second  cervical  to  the  sacrum, 
are  firmly  held  together  by  the  intervertebral  discs  lying  between  them, 
twenty-three  in  number.  The  discs  correspond  in  size  and  shape  to 
the  horizontal  surfaces  of  the  bodies  of  the  vertebrae  between  which 
they  are  found,  but  they  project  slightly  beyond  the  edges  of  the  verte- 
brae. The  sum  of  the  heights  of  all  the  discs  is  greatest  through  the 
middle  portion,  next  largest  through  the  "Snterior  borders,  and  least 
through  the  posterior  borders.  Singly  the  discs  vary  in  height  in  the 
different  regions  of  the  spine.  They  are  higher  anteriorly  in  the  cervical 
and  lumbar  regions  and  posteriorly  in  the  dorsal  region.  The  ratio 
of  the  height  of  the  discs  to  the  height  of  the  bodies  varies  according 
to  different  authors.  Weber  gives  the  ratio  of  the  average  height  of 
all  the  discs  to  the  average  height  of  all  the  vertebra?,  not  including  the 
sacrum,  as  i  :  5.  According  to  the  same  author  the  ratio  of  the  height 
of  all  the  discs  through  the  centers  to  the  height  of  the  vertebral  column. 


4  ANATOMY   OF   VERTEBRAL   COLUMN   AND   THORAX. 

represented  by  a  perpendicular  from  the  highest  point  of  the  atlas  to 
the  sacrum,  is  as  i  :  4. 

The  influence  of  the  discs  in  the  formation  of  the  physiological  curves 
of  the  spine  is  shown  by  the  two  curves  in  Fig.  5.  Curve  (a)  is  formed 
by  the  bodies  and  the  discs  together,  and  curve  (b)  is  the  result  obtained 
by  placing  the  bodies  one  upon  the  other,  forming  a  long  curve  with 
convexity  backward,  greatest  in  the  lower  dorsal  region.  The  con- 
vexity of  the  thoracic  spine  is  flattened  in  the  upper  part,  and  the  lumbar 


Fig.  3. — Median  Section  of  a  Portion  of  the  Adult   Lumbar  Vertebral  Column. 
The  Right  Half  Seen  from  the  Left. — {Pick.) 


and  cervical  physiological  curves  almost  completely  disappear  when  the 
discs  are  removed. 

"  The  discs  become  smaller  and  harder  with  age,  shrinking  to  a  greater 
extent  where  they  are  thickest  than  in  the  region  where  they  are  thin. 
For  this  reason  the  curve  of  the  spine  in  old  age  approaches  the  long 
convexity  backward  represented  by  curve  (h),  and  the  bowed  back 
of  old  age  is  substituted  for  the  upright  attitude  with  a  lumbar  forv\-ard 
curve  which  is  largely  due  to  the  influence  of  intervertebral  discs. 

The  discs  are  very  firmly  attached  to  the  bodies  of  the  vertebrae. 
On  the  anterior  surface  of  the  column  the  free  edge  of  the  disc  shows 


LIGAMENTS    OF   THE   SPINE. 


vmh 


Fig.  4.— Lines  Repre- 
senting THE  Sum 
OK  THE  Thickness 

OF    THE  InTERVER- 

1      TEBRAL      Discs. — 

V,  At  the  front  border; 
ni,  in  the  middle  of 
the  disc;  h,  at  the 
posterior  border. 


lamellc-e  consisting  of  fibers  passing  obliquely  from 
one  \ertebral  body  to  the  other.  The  fibers  of 
successive  lamelLne  are  at  right  angles  to  each 
other,  and  interlace,  suggesting  a  closed  lattice. 
At  the  upper  and  under  surfaces  the  fibers  pass 
into  the  thin  plates  of  half-calcified  hyaline  cartil- 
age covering  the  horizontal  surfaces  of  the  bodies. 
The  discs  are  also  attached  to  the  anterior  and  pos- 
terior common  ligaments  of  the  spine.  The  inter-" 
vertebral  discs  thus  furnish  a  connecting  structure 
of  great  strength  between  each  two  vertebrae,  and 


Fig.  5. — Curves  of  the  Vertebral  Column.— (i^/t/t.) 
A,  With  intervertebral  discs;  B,  without  intersertebral  discs. 

at  the  same  time  they  furnish  what  amounts  to  a 
ball-and-socket  joint,  on  account  of  the  incom- 
pressible fluid  pulp  in  the  center  of  each  disc,  be- 
tween each  two  vertebral  bodies,  except  of  course 
the  first  two  cervical. 

LIGAMENTS  OF  THE  SPINE. 
In  addition  to  the  connection  of  the  bodies  by 
means  of  the  intervertebral  discs  the  vertebrre  are 
bound  together  by  ligaments  which  serve  to  limit 
movement  between  them  and  contribute  stabilitv 
and  strength  to  the  column.     Ligaments  are  com- 


0  ANATOMY    OF   VERIEBR.\L   COLUMN   AND   THORAX. 

posed  of  white  fibrous  tissue,  the  strongest  tissue  in  the  body,  highly 
elastic,  but  non-extensible.  Two  of  .the  spinal  ligaments,  the  ligamentum 
nuch^e  and  the  subflava,  form  exceptions  to  this  statement,  being  made 
up  almost  entirely  of  yellow  fibrous  tissue. 

SACRO-ILIAC  ARTICULATION. 

The  strong  joint  between  the  sacrum  and  the  ilium  through  which 
the  whole  body-weight  is  transmitted  is  a  synchondrosis  which  permits 
but  little  motion.  \\Tiat  motion  occurs  between  the  sacrum  and  the 
ilia  consists  of  a  forward  and  backward  tilting  of  the  sacrum  on  the 
ilia  on  a  transverse  axis  passing  through  the  second  sacral  vertebra. 
If  the  top  of  the  sacrum  is  tilted  backward  because  of  the  obliquity 
of  the  articular  surfaces  the  ilia  are  separated.^ 

The  sacro-iliac  joint  is  made  safe  and  strong  in  part  by  the  wedge 
shape  of  the  sacrum,  but  chiefly  by  the  iliosacral  ligaments.  The  corre- 
sponding articular  surfaces  of  the  tv\-o  bones  are  covered  more  or  less 
completely  with  hyaline  articular  cartilage  and  the  ver}^  slight  joint  cav- 
ity between  them  is  crossed  by  fibrous  bands.  The  capsule  is  formed 
by  the  ligaments  surrounding  the  joint.  The  anterior  sacro-iliac  liga- 
ment is  thin,  and  consists  of  short  strong  fibers  passing  between  the 
adjacent  surfaces  of  the  sacrum  and  the  iliac  fossae.  The  posterior 
sacro-iliac  ligament  is  very  strong,  and  is  responsible  for  holding  the 
weight  of  the  trunk,  head,  and  arms  suspended  upon  the  pelvis  and 
is  usually  regarded  as  consisting  of  t^'O  portions.  The  short  posterior 
sacro-iliac  ligament  is  formed  by  bundles  of  fibers  passing  from  the 
first  and  second  transverse  tubercles  of  the  sacrum  to  the  rough  posterior 
part  of  the  inner  surface  of  the  ilium,  above  and  behind  the  auricular 
surface.  The  long  or  oblique  sacro-iliac  ligament  is  a  superficial  part 
of  the  short  ligament  and  is  a  band  of  fibers  extending  from  the  third 
and  fourth  transverse  tubercles  of  the  sacrum  to  the  posterior  superior 
spine  of  the  ilium. 

THOR-\X. 
The  thorax  is  a  bony  cage  containing  the  principal  organs  of  circu- 
lation and  respiration.  It  is  formed  by  the  thoracic  vertebrae,  the 
ribs,  the  costal  cartilages,  and  the  sternum.  The  ribs,  tn-elve  on  each 
side,  form  a  double  series  of  narrow,  curved,  flattened  bones  attached 
posteriorly  to  the  thoracic  vertebrae.     They  extend  at  first  outward, 

1  Goldthwait  and  Osgood:  "Bos.  Med.  and  Sur.  Jour.,"  INIay  25  and  June  i, 
1905,  with  literature. 


THE  THORAX. 


and  then  forward,  inward,  and  downward  toward  the  median  hne 
anteriorly.  The  seven  upper  ribs,  called  the  true,  sternal,  or  vertebro- 
sternal ribs^are  attached  directly  to  the  sternum  by  the  costal  cartilages 
anteriorly. /i he  five  lower  ribs  are  called  false  or  asternal  ribs;  the 
eighth,  ninth,  and  tenth  are  distinguished  as  vertebrochondral,  as  they 
are  anteriorly  indirectly  united  to  the  sternum  by  the  cartilage  of  the 
rib  or  ribs  above;  the  eleventh 
and  twelfth  are  called  floating 
ribs,  as  their  anterior  extremi- 
ties are  loose  in  the  abdominal 
wall.  The  ribs  increase  in 
length  from  the  first  to  the 
seventh  or  eighth,  decreasing 
from  the  eighth  to  the  twelfth. 
They  are  approximately  parallel 
with  the  exception  of  the 
eleventh  and  twelfth,  which 
slant  somewhat  more  down- 
ward. 

\  It  must  be  remembered  that 

1    ribs  are  lower  at  their  front  ends 

\    than  at  their  vertebral  connec- 

1  tion,  so  that  if  it  is  desired  to 
1  rotate  a  vertebra  by  pressure  on 
1  a  rib,  the  rib  horizontally  oppo- 
Isite  the  vertebra    is  not  to  be 
Vchosen.     It  has  been  shown'  in 
me  cadaver  (i)  that  rotation  of 
vertebras     may    be    produced, 
when    the    extremities  of    the 
spine    are    fixed,    by   pressure 
upon  any  of   the  intermediate 
ribs;  (2)  that  the  vertebrae  at- 
tached to  the  ribs  on  which  pres- 
sure is  made  are  the  most  affected;  (3)  that  the  rotation  never  equals 
the  rib  excursion;    (4)  that  the  most  efi"ective  points  for  pressure  or 
counterpressure  are  as  far  as  possible  from  the  midline  anteriorly  and 
posteriorly  except  on  the  lowest  four  ribs. 


Fig.  6.— Model  of  thk  Spine  Showing  the 
Anato.mical  Relations,  Especially  the 
Disposition  of  the  Soft  Parts  in  the 
Lumbar  Region. — (U'arien  Miiscmii.) 


^  Keene:  "Amer.  Jour,  of  Orth.  Sur.,"  July,  1906,  page  69. 


8  ANATOMY   OF    \'ERTEBRAL   COLUMN    AXD   THORAX. 

STERNUM. 
The  sternum  or  breast-bone  is  situated  in  the  median  line  of  the 
trunk,  completing  the  thoracic  cage  anteriorly.  As  a  whole,  the  ster- 
num is  a  flat  bone,  and  it  lies  directed  obliquely  fonvard  and  downward. 
It  consists  of  three  parts — the  manubrium  sterni,  the  gladiolus,  and  the 
ensiform  cartilage  or  xiphoid  process. 

SHAPE  AXD  BOUNDARIES  OF  THE  THORAX. 
In  shape  the  thorax  is  somewhat  conical,  larger  behind  than  in 
front  and  compressed  anteroposteriorly.     The  posterior  wall  is  formed 


Anterior  radi- 
ate or  stellate 
ligament 

['Costo-centra 
.. .  sj'novial  sac 


Fibrous  ring  of  inter- 
vertebral fibro-car- 
tilage 


Pulpy  nucleus  of  in- 
tervertebral fibro- 
cartilaare 


Costo-transverse  synovial  sac 


Posterior  costo-transverse  ligament 


Fig.  7.' 


-Horizontal  Section  through  an  Intervertebral  Fibro-cartilage  and  the 
Corresponding  Ribs. — (Morris'' s  "Anatomy.'") 


by  the  thoracic  vertebrae,  and  by  the  ribs,  from  their  heads  to  their 
angles,  and  is  convex  vertically  and  horizontally.  Laterally  the  cage 
is  formed  by  the  shafts  of  the  ribs;  it  is  somewhat  convex  vertically, 
and  sharply  convex  from  before  backward.  The  anterior  surface, 
slightly  convex  and  directed  fom-ard  and  downward,  is  formed  by  the 
sternum  and  the  costal  cartilages.  The  plane  of  the  superior  opening 
or  inlet  of  the  thorax  is  inclined  fonvard  and  do\vnward,  showing  a 
greater  obliquity  in  women  than  in  men.  The  inferior  border  of  the 
thoracic  cage  is  formed  by  the  twelfth  thoracic  vertebra,  the  lower 
borders  of  the  twelfth  rib,  and  by  two  curved  lines,  extending  from 
the  anterior  extremities  of  the  last  rib  to  the  inferior  angles  of  the  gladio- 


MUSCLES   OF  THE   SPINE  AND  THORAX. 


lus,  touching  the  anterior  extremities  of  the  elevfenth  rib  and  the  costal 
cartilages  of  the  tenth,  ninth,  and  eighth  ribs.  The  angle  formed  by 
these  lines  is  known  as  the  subcostal  angle.  The  inferior  surface  of 
the  thorax  is  directed  forward  and  downward. 


Fig.  8. — G.  Herman  Meyer.  The  Two 
Oblique  Mcscle  Pulls.— (j^^m.) 

On  the  left  the  descending  oblique,  a, 
External  intercostals ;  b,  descending- 
oblique  or  externus  abdominis.  On 
the  right  the  ascending  oblique  muscle 
pull.  c,  Descending  oblique  or  in- 
ternus  abdominis ;  d,  internal  inter- 
costals ;  e,  scalenus  colli  ;  f,  cre- 
master. 


Fig.  9.— G.  Herm.^n  Meyer.  The 
Scheme  of  the  Torso  Muscula- 
ture Indicating  the  Direction  of 
theVarious  Muscle  Pulls. — {Feiss.) 

a,  Posterior  longitudinal  muscle  pull 
(sacrospinalis) ;  <J,  anterior  longitudinal 
muscle  pull ;  c,  oblique  descending 
muscle  pull ;  d,  oblique  ascending  mus- 
cle pull ;  e,  transverse  muscle  pull. 


MUSCLES  OF  THE  SPINE  AND  THOR.\X. 
The  general  grouping  and  arrangement  of  the  muscles  in  their  rela- 
tion to  the  spine  has  an  important  practical  bearing  on  scoliosis.     The 
spine  lies  at  the  back  of  a  more  or  less  cylindrical  muscular  tube  of 
which  the  abdominal   muscles   form  the  front.     Of  muscles  directly 


lO 


ANATOMY   OF   \T.RTEBRAL   COLUMN   AND   THORAX. 


attached  to  the  spine  there  are  two  varieties:  (i)  muscles  running  from 
one  part  of  the  spine  to  another  part  and  to  the  head;  (2)  muscles 
running  from  the  spine  to  the  pelvis  or  shoulder-girdle.  The  abdominal 
muscles  by  their  attachment  to   the   thorax,  which  is  comparatively 


a, 


Fig.  10.— G.  Herman  Meyer.  The  Sys- 
tem OF  the  Sacrospinalis. — (Feiss.) 
Spinali.s;  b,  longissimus  dorsi ;  c, 
transversalis  cervicis ;  d,  trachelo- 
mastoideus ;  e,  ileocostalis ;  y,  as- 
cendens  cervices;  ^,  ileolumbalis 
(hinder  portion  of  m.  quadratus  luni- 
borum  Auct.);  A,  obliquus  capitis 
inferior;  /,  obliquus  capitis  superior; 
k,  rectus  capitis  posterior  major;  /, 
rectus  capitis  posterior  minor. 


Fig.  II.— G.'  Herman  Meyer.  Ante- 
rior Longitudinal  Muscles  of  the 
Trunk. — {J^eiss. ) 

a,  Sternocleido-mastoideus ;  b,  rectus  ab- 
dominis ;  c,  pyramidalis. 


rigid,  have  an  action  on  the  spine.  By  the  combined  action  of  these 
three  the  erect  position  is  maintained,  or  any  variation  from  it  is  ac- 
complished. 

In  making  a  side  flexion  of  the  spine  from  the  erect  position,  for 


NERVE-SUPPLY.  1 1 

example,  no  one  muscle  or  group  of  muscles  is  alone  active,  but  it  implies 
a  concerted  and  coordinated  action  of  all  the  groups  mentioned  to  keep 
the  balance  and  perform  the  bending.  The  maintenance  of  the  spine 
in  the  upright  position  by  the  muscles  has  been  compared  to  the  way 
in  which  a  flagstaff  is  held  upright  by  stays  reaching  from  the  top  of 
the  staff  to  the  ground.  Although  there  is  no  one  muscle  running 
from  the  head  to  the  pelvis  there  is  a  continuous  set  of  muscles  supple- 
menting each  other's  action.  For  example,  in  the  anterior  line  the 
sternomastoid  runs  from  the  skull  to  the  front  of  the  top  of  the  thorax, 
the  sternum  connects  the  vipper  and  lower  ribs  and  forms  a  rigid  piece, 
and  the  lower  thorax  is  connected  with  the  pelvis  by  the  rectus  abdominis 
muscle.  In  the  back  the  continuity  of  muscular  action  is  shown  by  the 
fact  that  before  the  top  insertion  of  the  longissimus  dorsi  has  been  reached 
the  complexus  and  transversalis  cervicis  have  begun.  The  whole  con- 
ception of  muscular  action  in  its  relation  to  gymnastics  is  simplified 
by  remembering  the  continuity  of  the  muscular  tube  from  the  head  to 
the  pelvis. 

The  thorax  represents  a  comparatively  fixed  cage  inserted  in  a  struc- 
ture quite  movable  above  and  below  it;  muscles  attached  to  the  thorax 
are  therefore  indirectly  attached  to  the  spine.  The  comparative  rigid- 
ity of  the  thoracic  part  of  the  spine  is  due  to  the  fact  that  the  majority 
of  the  ribs  are  attached  between  two  vertebrae,  that  they  pass  forward 
to  be  also  attached  to  the  sternum,  and  that  the  whole  structure  is  one 
well  calculated  to  prevent  side  bending  or  extensive  forward  or  back- 
ward motion  in  that  region;  the  cage  must  therefore  largely  move  as 
a  whole. 

It  has  been  pointed  out  that  the  dorsolumbar  junction  is  a  dividing 
point  for  important  muscular  origins  and  insertions  above  and  below 
it,  e.  g.,  the  psoas  muscles  originate  largely  below  it  and  the  trapezius 
above  it,  and  that  it  forms  a  weak  and  movable  part  of  the  spine  for 
this  reason  (Ludloff),  but  more  important  than  this  is  the  fact  that  mus- 
cles connecting  the  thorax  and  pelvis  will  move  the  spine  where  the  rigid 
dorsal  region  changes  to  the  movable  lumbar  region  and  that  a  large 
number  of  muscles  will  therefore  express  their  contraction  by  motion 
at  the  dorsolumbar  junction.  A  similar  Aveak  and  movable  part  of 
the  spine  is  said  to  exist  at  the  cervicodorsal  junction,  where  important 
muscles  (splenius  and  rhomboids)  have  a  dividing  point. 

NERVE-SUPPLY. 
The  spinal  nerves  emerge  from  the  spinal  canal  through  the  inter- 
vertebral foramina  and  are  distributed  to  the  integument  and  muscles 


ANATOMY   OF   VERTEBRAL   COLUMN   AND   THORAX. 


MOTOR 


Sterno-:mastoid 
Trapezius 


SENSORY 

Neck  and  scalp 
I  Neck  and  shoulder 

Shoulder 

Arm 

Hand 


REFLEX 


Scapular 


■  Front  of  thorax 


-Xiphoid  area 


Abdominal 
muscles 


Flexors,  hip 

Extensors,  knee 

I    ^Adductors 
J  i 


Epigastric 


hip 


j-  Abductors 

J  Extensors(?) . 
'i  Flexors,  knee  (?) 

Muscles     of     leg 
moving  foot 


•Abdomen 
(Umbilicus  loth) 


(.Buttock,  upper 
j  part 

Groin  and  scrotum 
(front) 

outer  side 


.  Thigh 


[  iimer  side 
Leg,  inner  side 
f  Buttock,  lower 
I  part 


i  Back  of  thigh 

Leg) 

and  -except  in- 
Ifoot)    ner  part 


Abdominal 


Cremasteric 
I  Knee-jomt 

Gluteal 

Foof-clonus 
Plantar 


I  Perinseal   and    anal      |-  Perinceum  and  anus 


muscles 


'-  Skin    from    coccyx 
j  to  anus 


Fig.  I2.-DIAGRAM  and  Table  showing  the  Approxi.mate  Relation  to  the  Spinal 
Nerves  OF  the  Various  Motor,  Sensory,  and  Reflex  Functions  of  the  Spinal 
Cord.  (Arranged  by  Dr.  Gowers  from  anatomical  and  pathological  data.)-(7l/or7-Ji  s 
'■'Anatomy .") 


OSSIFICATION.  13 

all  over  the  body.  Eight  are  cervical  nerves  (the  first  passing  over  the 
atlas),  twelve  dorsal,  five  lumbar,  five  sacral,  and  one  coccygeal.  Each 
is  formed  by  the  union  of  two  nerve  roots,  which  occurs  outside  the 
spinal  cord  and  just  inside  of  or  at  the  intervertebral  foramen.  The 
anterior,  motor,  or  efferent  fibers  come  from  the  cells  of  the  .anterior 
horn  of  the  cord ;  the  posterior,  sensory,  or  afferent  fibers  emerge  from 
the  cells  of  the  posterior  horn  on  the  same  side  of  the  cord.  The  nerve 
formed  by  these  two  roots  on  leaving  the  intervertebral  foramen  divides 
into  an  anterior  and  posterior  branch,  each  with  motor  and  sensory 
fibers.  The  posterior  divisions  are  small  and  supply  the  skin  and 
muscles  of  the  back.  The  anterior  divisions  are  distributed  to  the  neck, 
the  front  and  sides  of  the  trunk,  and  to  the  extremities.  Each  ante- 
rior division  is  connected  with  a  plexus,  ganglion,  or  nerve  of  the  sym- 
pathetic system. 

EVOLUTION  OF  THE  SPINE. 
The  history  of  the  spine  in  its  evolution  is  of  interest.  In  the  Cyclo- 
stomata  the  vertebral  column  consists  of  a  non-segmented,  homogeneous, 
cartilaginous  rod.  Articular  processes  first  appear  in  the  Rays  and 
Teleostei.  The  backbone  of  the  lower  fishes  consists  of  a  series  of  bony 
discs  bound  together  by  elastic  intervertebral  discs.  It  would  seem  from 
the  history  of  the  spine  as  if  articular  processes  developed  concomitantly 
with  the  elaboration  of  structure,  as  if  they  were  incidental  to  its  use 
rather  than  factors  determining  of  themselves  its  types  of  motion. 

OSSIFICATION. 
The  ossification  of  a  vertebra  occurs  from  three  primary  centers, 
one  for  the  body  and  one  for  each  lateral  mass.  These  appear  in  the 
sixth  week,  and  in  the  cervical  region  the  lateral  centers  are  the  first 
to  appear,  while  in  the  dorsal  region  the  one  for  the  body  is  the  first 
seen.  The  center  for  the  body  is  often  double  in  appearance  if  not 
in  reality.  The  centers  for  the  lateral  masses  are  found  near  the  bases 
of  the  articular  processes  and  from  them  form  the  pedicles,  laminae, 
articular  processes,  and  a  large  part  of  the  transverse  and  spinous  pro- 
cesses, the  bodies  of  the  vertebrae  forming  from  the  other  center.  The 
vertebral  epiphyses  serve  to  assist  in  the  formation  of  joints,  to  provide 
for  the  attachment  of  ligaments  and  tendons,  and  to  increase  the  devel- 
opment in  length  of  the  bone  of  which  they  form  a  part.  At  about 
puberty  appear  five  other  secondary  or  complementary  centers,  one  at 
the  tip  of  the  spinous  process,  one  at  the  tip  of  each  transverse  process, 
and  one  at  the  upper  and  one  at  the  lower  surface  of  each  body,  occur- 


14 


ANATOMY   OF   VERTEBRAL   COLUMN   AND   THORAX. 


ring  as  a  flat  meniscus  at  about  the  seventeenth  year  and  uniting  to 
the  vertebral  body  a  few  years  later  (twenty  years).  The  arrest  of  the 
development  of  one-half  of  one  of  these  latter  may  become  a  serious 
matter. 

PLANES  OF  THE  BODY. 
The  planes  of  the  body  will  be  frequently  spoken  of  and  should  be 
defined.     The  frontal  plane  is  a  vertical  and  transverse  one.     The 
sagittal  or  anteroposterior  plane  runs  in  the  anteroposterior  axis.     The 
term  horizontal  plane  is  self-explanatory- 

Epiphyseal  plate  or  disc 


Mammillary  tubercle 
Transverse  process 


—  Spinous  process 


EpipliNseal  plate  or  disc 


Fig.  13.— Lumbar  Vertebra   at  the  Eighteenth  Year  with  Secondary  Centers.- 
{Morris's  "Anafotny.") 


Pedicle 

Neuro-central  suture 
Centrum 


Fig.  14.— Ossification  of  the  Fifth  Lumbar  Vertebra— (Morris' s  "Aiiatonir.") 


PHYSIOLOGICAL  CURVES. 

In  examining  the  literature  relating  to  the  physiological  curves  such  contradictory 
and  unsatisfactory  information  was  found  that  the  whole  subject  was  taken  up  by 
the  writer  for  investigation,  the  results  of  which  are  presented  here.^ 

In  this  investigation  the  position  of  the  spine  in  the  human  embryo  was  studied. 
The  spinal  curves  of  the  skeletons  of  mammalia  were  observed.  Measurements 
were  made  of  the  anterior  and  posterior  borders  of  the  bodies  of  the  vertebras  in 
sagittal  section  of  the  spine  of  new-born  children  and  of  a  child  two  years  old,  and 

iprom  a  paper  presented  at  the  Italian  Congress  of  Orth.  Sur.,  "Arch,  di 
Ortop.,"  1906,  V  and  vi,  page  372,  Milan,  Sept.  22,  1906. 


PHYSIOLOGICAL   CURVES. 


15 


lead  strip  tracings  were  taken  of  the  back  of  two  hundred  normal  children  between 
the  ages  of  four  days  and  thirteen  years  in  the  positions  of  slack  standing,  natural 
standing,  and  in  prone  lying. 

Measurements  of  medial  sections  of  detached  spines  showed  in  new-born 
infants  a  slight  bony  curve  in  the  lower  dorsal  region,  convex  backward.  This 
curve  was  visible  on  the  anterior  surface  of  the  column  and  reappeared  after  cor- 
rective manipulation  of  the  spine.  The  curve  of  the  spine  of  a  child  two  years  old 
was  more  developed  than  in  the  new-born.  Measurement  of  the  anterior  and  pos- 
terior borders  of  the  vertebral  bodies  showed  in  the  cervical  region  a  difference 
of  0.5  mm.  in  favor  of  the  anterior  borders,  in 
the  dorsal  region  a  difference  of  16  mm.  in  favor 
of  the  posterior  borders,  and  in  the  lumbar  spine 
9.5  mm.  in  favor  of  the  anterior  borders.  In 
this  spine  therefore  the  three  physiological  curves 
were  present  in  the  bodies  of  the  vertebrae. 

Tracings  over  the  spinous  processes  were 
taken  by  means  of  flexible  lead  strips  and  the 
curves  transferred  to  paper  for  study.  The  trac- 
ings showed  clearly  the  form  and  development 
of  the  dorsal  and  lumbar  curves  in  standing  and 
in  lying  prone.  The  natural  sitting  position  as- 
sumed by  all  the  children  was  practically  the 
same,  a  convexity  backward  of  the  dorsal  and 
lumbar  spines  with  a  maximum  at  the  dorso- 
lumbar  junction.  In  the  younger  children  this 
curve  included  the  sacrum.  Only  four  of  the 
children  between  the  ages  of  nine  and  thirteen 
showed  a  lumbar  curve  in  sitting.  "  The  char- 
acter of  the  curves  varied  most  in  the  youngest 
children,  and  became  more  constant  with  age. 
The  variations  from  the  accepted  normal  type 
of  tracing  were  most  numerous  in  the  youngest 
children,  and  decreased  in  percentage  and  in 
variety  with  age. 

In  lying  the  backward  dorsal  curve  was  found 
in  86  per  cent,  of  cases  under  one  year,  and  in 
all  but  two  of  the  178  children  over  one  year 
old.  The  curve  was  marked  at  fourteen  months, 
and  increased  with  age.     In  children  under  six 

months  the  curve  included  the  lumbar  and  sacral  regions;  in  those  over  six  months 
it  did  not.  The  lumbar  curve  in  lying  showed  frequently  after  the  age  of  one  year, 
and  in  a  very  large  majority  of  cases  after  the  age  of  three  years.  The  cervical 
curve  could  not  be  observed  to  advantage  in  lying,  or  in  standing,  in  the  }'oungest 
children,  but  over  the  age  of  fourteen  months  a  cervical  curve  with  anterior  con- 
vexity was  observed  in  standing.  The  dorsal  curve  appeared  in  standing  in  the 
earliest  tracing  in  this  position,  that  of  a  child  ten  months  old,  and  persisted  abso- 
lutely. The  curve  was  well  marked  at  fourteen  months  and  increased  with  age, 
changing  in  character  as  it  became  limited  to  the  dorsal  spine,  and  the  maximum 
receded  from  the  dorsolumbar  junction  to  the  middorsal   region.     The  dorsal 


Fig.  15.— Section  of  the  Spine 
OF  A  New-born  Infant. 


i6 


ANATOMY   OF   VERTEBRAL    COLUMN   AND   THORAX. 


curve  was  greater  in  standing  than  in  lying.  The  lumbar  curve  in  standing  appeared 
first  in  a  child  of  seventeen  months,  and  from  the  age  of  two  years  persisted  in  a 
very  large  majority  of  cases,  the  exceptions  being  usually  children  under  three 
years  who  had  not  walked.  The  curve  increased  ai  the  expense  of  the  dorsal 
curve,  and  was  usually  greater  in  standing  than  in  lying. 


GIRL 

1/2  YRS 

Sitting   Front 


-7^"C 


Standing 


.7THC 


.4^"L 


4THL. 


.4"^"R 


Fig.  16. — Tracings  of  Physiological  Curves  of  Normal  Children,  on  the  Left  of 
A  Girl  of  One  and  a  Half  Years,  on  the  Right  of  a  Girl  of  Eleven. 


In  the  adult,  the  part  played  by  the  bodies  of  the  vertebrae  and  the  discs  in 
producing  the  physiological  curves  is  shown  by  the  following  table: 


DiiTERENCE  Between  the  Sums  of  the  Anterior  and  Posterior  Borders. 

VERTEBR.3E.  DiSCS. 

Cervical  region 1.3  mm.  7.8  mm. 

Dorsal  region 13.3  mm.  9.2  mm. 

Lumbar  region 6.7  mm.  21. i  mm. 


PELVIC   INCLINATION. 


17 


The  cervical  curve  is  formed  principally  by  the  intervertebral  discs. 
It  is  a  fairly  mobile  curve,  and  may  be  straightened  by  suspension. 
The  dorsal  curve  is  formed  chiefly  by  the  bodies  of  the  vertebrae ;  it  is 
a  rigid  curve  and  cannot  be  obliterated.  The  lumbar  physiological 
curve  is  produced  mainly  by  the  greater  anterior  height  of  the  inter- 
vertebral discs  and  is  therefore  mobile. 

A  slight  physiological  lateral  curve  convex  to  the  right  has  long  been 
recognized  in  the  spine.  It  has  been  attributed  to  the  pressure  of  the 
aorta  on  the  vertebral  bodies,  to  excessive  use  of  the  right  side  of  the 
body  in  certain  occupations,  and  to  extreme  right-handedness.  The 
almost  constant  occurrence  of  the  curve  indicates  a  common  cause, 
which  is  most  probably  aortic  pressure.  The  asymmetry  extends  from 
the  fifth  dorsal  to  the  second  or  third  lumbar  vertebra.  The  body 
of  the  fifth  dorsal  vertebra  is  flattened  on  the  left  side,  and  the  discs 
above  and  below  are  similarly  affected.  There  is  a  groove  from  one 
and  a  half  to  two  centimeters  broad  passing  downward  in  a  spiral 
direction,  following  the  course  of  the  aorta,  to  the  anterior  surface  of 
the  second  or  third  lumbar  vertebra.  The  discs  between  these  verte- 
bras are  usually  less  projecting  than 
the  others,  and  if  the  cutting  away 
of  the  vertebra  cannot  be  seen  the 
flattening  of  the  disc  is  always  ap- 
parent.^ 

PELVIC  INCLINATION. 
The  position  of  the  pelvis  in 
relation  to  the  horizontal  plane  is  of 
importance  in  relation  to  scoliosis 
and  faulty  attitude  because  it  must 
vary  from  the  normal  with  every 
variation  from  the  normal  of  the 
body  in  the  upright  position.  If 
the  front  part  of  the  pelvis  is  low- 
ered a'ld  the  back  part  correspond- 
ingly tilted  up  it  is  spoken  of  as 
"increased    inclination."      If    the 

front  part  is  raised  and  the  back  part  lowered  it  is  spoken  of  as 
"diminished  inclination."  With  the  former  is  associated  an  increase 
of  the  lumbar  physiological  curve  and  with  the  latter  a  flattening  of  it.« 

^  Pere:  "Les  courb.  lat.  norm  du  Rachis  humaine,"  These  de  Toulouse, 
1900. 


Fig.  17. — Female  Pelvis,  Median  Sec- 
tion.— (Spalteholz.) 
The  solid  line  running  up  and  back  from 

the  symphysis  indicates  the  "  external 

conjugate  diameter." 


l8  ANATOMY   or    \'KRTEBRAL   COLUMN   AND   THOR.\X. 

Changes  in  inclination  of  the  pelvis  form  an  important  element  in  the 
faulty  attitude  to  be  spoken  of  as  round  shoulders,  but  have  been  to  a 
certain  extent  overlooked. 

The  internal  or  true  conjugate  diameter  (conjugata  vera)  of  the  pelvis  is  a 
line  from  the  sacrolumbar  junction  to  the  top  of  the  symphysis  pubis  and  is  gen- 
erally accepted  as  the  line  by  which  pelvic  inclination  is  to  be  determined.  The 
angle  which  this  line  makes  with  the  horizon  when  the  patient  stands  erect  is  spoken 
of  as  the  "angle  of  pelvic  inclination,"  and  the  observers  do  not  wholly  agree  in 
their  results,  which  are  as  follows: 

Average  in  Men.  Average  in  Women. 

Year  1745,  Mtiller 45  degrees 

Year  1825,  Nagele^ 60        " 

Year  1836,  Weber  Brothers' 65- degrees 

Year  1841,  Krause^ 60        "  60        " 

Year  1873,  Meyer* 55        "  50        " 

Year  1882,  Prochovnik^ 54-i7  "  5i-72  " 

Year  1898,  Henggeler^ 44        "  41. i     " 

The  question  has  been  chiefly  studied  by  gynecologists  and  obstetricians,  and 
from  their  point  of  view  most  of  the  work  was  done  over  twenty-five  years  ago. 
Prochovnik's  method  of  observation  commends  itself  as  reliable,  and  his  conclusions 
are  therefore  worthy  of  consideration.  He  observed  living  patients,  whereas  many 
of  the  other  observations  were  on  cadavers.  He  measured  the  patient  standing 
and  took  in  front  the  height  from  the  ground  of  the  top  of  the  sjTiiphysis  pubis  and 
the  height  of  the  fifth  lumbar  spinous  process  behind.  The  distance  between  these 
two  was  then  measured  and  the  inclination  thus  determined  of  a  line  connecting 
the  fifth  lumbar  spinous  process  and  the  top  of  the  os  pubis,  a  line  differing  but 
little  from  the  true  conjugate.  This  he  called  the  external  conjugate  and  used  as 
the  basis  of  all  his  calculations.  By  adding  from  8  to  12  degrees  to  his  measure- 
ments the  true  conjugate  is  to  be  found. 

Seventy-six  males  and  eighty  females,  all  apparently  normal,  over  the  age  of 
fifteen  were  investigated  and  tabulated. 

Le.\st  Inclination.  Greatest.  Average. 

Males 26     degrees  76  degrees  51.72  degrees 

Females 40.5        "  71        "  54-17        " 

The  grouping  of  the  results  suggests  that  a  normal  pelvis  shows  an  inclination 
of  from  50  to  60  degrees,  that  there  is  a  subnormal  zone  from  45  to  50  degrees,  a 
supranormal  of  60  to  65  degrees,  but  that  an  inclination  above  65  degrees  or  below 
45  degrees  is  to  be  regarded  as  pathological.  The  figures  given  refer  to  the  external 
conjugate  and  are  a  little  higher  when  the  internal  conjugate  is  taken  as  determining 
the  angle  of  inclination.     The  variation  in  the  inclination  of  the  pelvis  in  individ- 

^  "Das  Weibl  Becken,"  etc.,  Carlsruhe,  1825. 

^  "Mech.  d.  Menschl.  Gehwerkzeuge.,"  Gottingen,  1836. 

^  "Hdbch.  d.  Mensch.  Anat.  Hauft.,"  i,  i,  324,  Hanover,  1841. 

*  "Miiller's  Archiv,"  1873,  9. 

^  "Archiv.  f.  Gyn.,"  1882,  xix,  i. 

"  "Zeitsch.  f.  orth.  Chir.,"  xii,  4,  613. 


NUMERICAL   VARIATION.  1 9 

uals  is  so  wide  that  the  average  has  but  little  meaning  in  any  individual  case.  The 
angle  which  the  long  axis  of  the  leg  makes  with  the  horizon  as  seen  from  the  side 
in  the  upright  position  varies  a  good  deal,  being,  on  the  whole,  a  larger  angle  for 
men  than  for  women  (8o|  degrees  in  men  and  77  degrees  in  women);  that  is,  the 
leg  axis  in  women  is  more  oVjlique  and  less  vertical  than  in  men  (Prochovnik). 

In  the  normal,  upright  position  the  anterior  superior  spines  of  tlje  ilium  and 
the  tubercle  of  the  os  pubis  are  in  the  same  vertical  plane.  This  was  found  true 
by  Meyer  and  Prochovnik  and  is  at  least  true  for  Germans.  The  fact  is  of  impor- 
tance in  determining  the  normal  inclination  of  the  pelvis  during  life  and  in  measure- 
ments of  cadavers. 

The  inclination  of  the  pelvis  is  influenced  by  the  position  of  the  legs.  In  the 
widest  possible  spread  of  legs  (27J  degrees  in  men  and  22^  degrees  in  women) 
the  inclination  of  the  pelvis  is  increased  on  the  average  by  i8i  degrees  in  men  and 
16^  degrees  in  women.  The  angle  between  the  lumbar  spine  and  external  con- 
jugate of  the  pelvis  is  not,  however,  greatly  changed  by  this  position,  as  the  lumbar 
spine  changes  also.  The  angle  in  the  normal  upright  position  with  the  legs  together 
being  148  degrees,  with  the  legs  spread  it  becomes  154  degrees  in  men  and  146 
degrees  in  women,  a  difference  of  only  a  few  degrees. 

As  the  method  of  Prochovnik  is  slow  and  tedious,  Henggeler  attempted  to  find 
an  available  practical  measure  of  the  pelvic  inclination  in  the  obliquity  of  a  line 
connecting  the  anterior  and  posterior  superior  iliac  spines,  and  made  661  measure- 
ments for  this  purpose  on  children  for  the  most  part  scoliotic  or  with  other  abnor- 
mality. Knowing  the  obliquity  of  this  line  he  attempted  to  translate  it  into  terms 
of  obliquity  of  the  conjugate  diameter  by  means  of  anatomical  measurements  made 
on  the  pelves  of  eight  male  and  fifteen  female  adult  cadavers.  He  estimated  that 
to  obtain  the  inclination  of  the  conjugate  there  should  be  added  to  the  inclination  of 
the  line  connecting  the  two  superior  iliac  spines  a  "  constant"  which  in  the  measure- 
ments varied  from  24.5  degrees  to  47  degrees,  with  an  average  for  men  of  32  degrees 
and  for  women  of  35.5  degrees. 

Inasmuch  as  the  results  of  these  measurements  differ  so  widely  from  those  of 
other  observers,  as  the  clinical  material  consisted  largely  of  scoliotic  children,  and 
as  the  "constant"  was  obtained  from  the  study  of  adult  pelves  and  applied  to  the 
measurements  of  children's  pelves,  it  is  not  possible  to  attach  the  same  importance 
to  these  figures  as  to  those  of  Prochovnik,  and  this  low  pelvic  inclination  cannot 
be  accepted  without  more  extended  investigation. 

With  regard  to  pelvic  inclination  in  children  there  are  no  figures  upon  which 
we  can  rely  to  determine  whether  it  is  greater  or  less  than  in  adults. 

NUMERICAL  VARIATION  IN  THE  VERTEBRAL  COLUMN. 

The  number  of  vertebrae  in  the  different  regions  of  the  spine  may  vary,  and 
the  subject  has  a  distinct  bearing  on  the  etiology  of  scoliosis.'  Numerical  variation 
in  the  human  spine  is  estimated  by  Bardeen  as  .occurring  in  15  or  16  per  cent,  of 
people.  The  following  classification  of  the  abnormal  spines  in  the  Dwight  collec- 
tion in  the  Warren  Anatomical  Museum  will  show  the  more  usual  forms.^ 

I.  The  number  of  presacral  vertebrae  is  normal,  but  there  is  an  irregularity  at 
the  junction  of  the  dorsal  and  lumbar  or  dorsal  and  cervical  regions. 

'  Fischel:  "  Untersuchungen  liber  die  Wirbelsaiile  und  dem  Brustkorb,  des 
Menschen,"  Wiesbaden,  1906. 

^Thomas  Dwight:   "Mem.  Bos.  Soc.  of  Nat.  Hist.,"  v,  7,  1901.. 


20  ANATOMY   OF   \^RTEBKAL   COLUMN   AND  THORAX. 

2.  In  some  specimens  the  twenty-sixth  presacral  vertebra  is  the  one  forming 
the  largest  part  of  the  auricular  surface  in  contact  with  the  ilium  {vertebra  fulcralis), 
but  in  which  the  twenty-fifth  is  not  quite  separated  from  it. 

3.  There  may  be  more  than  twenty-four  perfectly  free  presacral  vertebras, 

(a)  the  extra  one  being  thoracic,  (b)  or  lumbar,  (c)  or  both  thoracic  and  lumbar, 
the  latter  being  sacralized  on  one  side  and  the  twenty-seventh  the  vertebra  fulcralis. 

4.  One  or  more  presacral  vertebrae  may  be  imperfectly  developed — (a)  one  or 
more  being  fused,  (6)  the  atlas  and  occiput  being  fused,  (c  and  d)  the  twenty-fourth 
being  more  or  less  sacralized, 

5.  There  may  be  lacking  one  presacral  vertebra — (a)  in   the  lumbar  region, 

(b)  in  the  thoracic  region,  (c)  there  being  twelve  pairs  of  ribs,  the  first  pair  being 
cervical  and  perfect  on  one  side.  The  twenty-fourth  is  the  vertebra  fulcralis  in 
all  groups  of  this  division. 

The  two  sides  of  the  column  may  vary  independently,  a  point  of  much  impor- 
tance. Clinically  these  variations  are  described  as  cervical  ribs,  Ivmibar  ribs, 
extra  lumbar  vertebrae,  sacralized  vertebrae,  deficient  vertebras,  etc. 

When  present  these  variations  are  usually  at  the  regional  boundaries  and  are 
found  more  frequently  toward  the  posterior  end  of  the  spine  than  anteriorly. 

The  numerical  anomalies  which  occur  may  be  called  a  variation  around  a 
mean.  The  error  in  development  having  once  occurred,  there  is  evident  an  effort 
on  the  part  of  the  organism  to  correct  it  as  much  as  possible.  If  there  are  but  eleven 
thoracic  vertebrae  the  bodies  very  often  are  longer  than  usual.  If  the  last  rib  be 
rudimentary  the  penultimate  is  unusually  long;  if  there  be  an  irregularity  in  the 
lumbar  vertebrae  an  effort  is  apparent  to  imitate  the  usual  aspect  of  the  region 
as  nearly  as  may  be  in  the  spread  of  the  transverse  processes.  In  cases  where 
the  last  rib  is  like  a  transverse  process  and  there  are  only  four  lumbar  vertebrae, 
the  appearance  is  often  very  striking. 

The  thorax  may  be  segmentally  reduced  or  extended  at  either  end,  extended 
at  both  ends,  or  extended  at  one  end  and  reduced  at  the  other;  a  simultaneous 
reduction  at  both  ends  has  not  been  reported. 

According  to  Bardeen,'  the  original  position  of  the  ilium  is  opposite  the  anterior 
part  of  the  lumbar  region,  and  in  development  it  travels  downward.  When  once 
it  has  joined  a  vertebra  it  never  leaves  it.  The  junction  of  the  spine  and  the  ilium 
occurs  about  the  end  of  the  fifth  week.  No  chondrification  has  yet  occurred,  but 
there  is  no  subsequent  change  in  segmentation.  Even  at  this  early  period  the 
thoracic  vertebrae  are  differentiated  from  the  others.  Consequently  an  increase 
or  decrease  in  the  number  of  thoracic  vertebrae  is  not  necessarily  determined  by 
the  point  at  which  the  ilium  stops  in  its  migration  taUward,  but  presumably  depends 
on  an  error  of  segmentation  (D wight,  Fischel), 

Speaking  broadly,  these  variations  may  be  regarded  as  being  variations  (a)  in 
a  cranial  direction,  {b)  in  a  caudal  direction;  in  the  former  all  the  regional  bounda- 
ries are  placed  higher,  there  being  only  six  cervical  vertebrae;  in  the  latter  the  regional 
boundaries  are  lower  than  normal.  The  vertebrae  at  the  regional  boundaries  are 
called  "transitional  vertebrae"  and  have  the  features  of  both  regions. 

The  present  condition  as  to  the  meaning  of  these  variations  is  expressed  by 
Dwight  as  follows:    "The  cause  of  the  original  error  is  as  yet  undetermined,  but 

^"Numerical  Variation  in  the  Human  Adult  and  Embryo. "  "Anat.  Anz., " 
Bd.  XXV,  1904. 


SURFACE   ANATOMY.  21 

there  is  no  reason  to  suppose  that  it  is  either  hereditary  or  a  step  toward  the 
future." ' 


SURFACE  ANATOMY  OF  THE  BACK. 

The  position  of  the  spine  in  the  median  line  of  the  body  is  indicated 
on  the  normal  back  by  a  longitudinal  furrow  (median  furrow)  extending 
from  the  occipital  bone  to  the  sacrum.  The  lower  end  of  the  furrow 
corresponds  to  the  interval  between  the  fifth  lumbar  vertebra  and  the 
sacrum.  In  the  cervical  region  this  furrow  lies  between  the  trapezii  and 
complexi,  and  in  the  dorsal  and  lumbar  regions  it  lies  between  the  erec- 
tor spinse  muscles.  It  is  usually  most  marked  in  the  upper  lumbar  and 
lower  dorsal  regions. 

Identification  of  Vertebrce. — In  this  median  furrow  the  spinous  pro- 
cesses of  the  lower  cervical  vertebrae  can  be  felt;  in  a  poorly  developed 
individual  they  can  be  seen  in  the  erect  position,  and  in  one  well  de- 
veloped in  forward  bending.  The  upper  cervical  vertebrae  lie  too  deeply 
to  be  either  seen  or  felt.  The  spinous  process  of  the  seventh  cervical 
vertebra  is  usually  quite  prominent,  though  that  of  the  first  thoracic  is 
still  more  so.  In  proceeding  downward  the  root  of  the  spine  of  the  scapula 
should  be  found  opposite  the  spinous  process  of  the  third  dorsal  vertebra, 
and  the  inferior  angle  of  the  scapula  opposite  that  of  the  seventh  dorsal 
vertebra.  The  spine  of  the  fourth  lumbar  vertebra  is  on  a  level  with  the 
highest  points  of  the  iliac  crests.  The  spinous  process  of  the  fifth  lumbar 
vertebra  is  very  short,  and  usually  forms  a  slight  depression  instead  of  a 
prominence.  The  third  sacral  vertebra  is  on  the  line  drawn  between  the 
posterior  superior  spines  of  the  ilium.  The  twelfth  dorsal  vertebra  is 
found  by  counting  down  from  the  seventh  dorsal  and  up  from  the  fourth 
lumbar  vertebra,  and  any  vertebra  may  be  found  in  this  way.  Of  these 
methods  the  latter  is  the  more  reliable.  In  the  dorsal  region  the  ob- 
liquity of  the  spinous  processes  causes  the  tip  of  each  to  be  opposite  the 
body  of  the  vertebra  next  below  it.  So  the  spine  of  the  second  dorsal 
vertebra  corresponds;  to  the  head  of  the  third  rib,  but  the  eleventh  and 
twelfth  dorsal  spines  are  opposite  the  heads  of  the  eleventh  and  twelfth 
ribs.  The  spinous  processes  of  the  lumbar  vertebrae  are  opposite  the 
lower  parts  of  the  corresponding  bodies  and  the  discs  below  them. 

In  the  adult  the  spinal  cord  ends  at  the  lower  border  of  the  first 
lumbar  vertebra ;  in  children  the  cord  terminates  at  the  lower  border  of 
the  third  lumbar  vertebra. 

Muscles. — The  outline  of  the  neck  posteriorly  is  formed  by  the 
'Rosenberg:    '^Morph.  Jahrb.,"  xxvii,  S.  1-18S. 


22  ANATOMY   OF   VERTEBRAL   COLUMN  AND   THORAX. 

trapezii  and  underlying  muscles.  The  surface  of  the  shoulder  is  shaped 
by  the  deltoid  and  the  muscles  underlying  the  trapezius.  The  posterior 
border  of  the  axilla  is  formed  by  the  latissimus  dorsi,  which  also  takes 
part  in  forming  the  contour  of  the  lower  part  of  the  back.  In  action  the 
anterior  edge  of  the  latissimus  dorsi  may  be  seen  as  a  fold  extending 
from  the  crest  of  the  ilium  to  the  axilla.  The  erector  spinse  muscles 
form  a  rounded  prominence  longitudinally  on  either  side  of  the  spine  in 
the  lumbar  region. 

The  following  table  from  Gray's  "Anatomy"  gives  the  relation  of  the 
spines  of  the  vertebrae  to  important  organs : 

Tabular  Plan  of  Parts  opposite  the  Spines  of  the  Vertebra  (Gray). 

P  /  Sth.   Cricoid  cartilage.     Esophagus  begins. 

\  7th.  Apex  of  lung :   higher  in  the  female  than  in  the  male. 

f     3d.  Aorta  reaches  spine.     Apex  of  lower  lobe  of  lung.     Angle 

I  of  bifurcation  of  trachea. 

I     4th.  Aortic  arch  ends.     Upper  level  of  heart. 

I      Sth.  Lower  level  of  heart.     Central  tendon  of  diaphragm. 

I     9th.  Esophagus    and    vena    cava    through    diaphragm.     Upper 

Dorsal -i  edge  of  spleen. 

loth.  Lower  edge  of  lung.     Liver  comes  to  surface  posteriorly. 

Cardiac  orifice  of  stomach, 
nth.  Lower  border  of  spleen.     Renal  capsule. 
12th.  Lowest   part  of   pleura.  ■  Aorta   through  diaphragm.     Py- 
lorus. 

f      I  St.  Renal  arteries.     Pelvis  of  kidney. 
I       2d.  Termination   of  spinal   cord.     Pancreas.     Duodenum  just 

Lumbar -j  below.     Receptaculum  chyli. 

I       3d.  Umbilicus.     Lower  border  of  kidney. 
[     4th.  Division  of  aorta.     Highest  part  of  ilium. 

Points  for  Lateral  Corrective  Pressure. — The  points  at  which  cor- 
rective side  pressure  may  be  applied  to  the  spine  are  determined  by 
anatomical  conditions.  The  structures  lying  on  both  sides  of  the  spine 
w  in  the  cervical  and  lumbar  regions  prevent  the  use  of  lateral  corrective 
i  force  in  these  regions.  In  the  dorsal  region  side  pressure  on  the  ribs 
is  effective  on  the  vertebrae,  but  it  cannot  be  exerted  on  the  upper  ver- 
tebrae higher,  of  course,  than  the  axilla.  The  anterior  border  of  the 
axilla  is  formed  by  the  pectoralis  major  muscle  and  is  in  the  line  of 
the  fifth  rib.  This  rib  articulates  with  both  the  fourth  and  fifth 
dorsal  vertebrae.  Although  with  the  arm  nearly  at  the  side  the  third 
rib  may  be  reached  by  the  exploring  hand,  side  pressure  on  the  thorax 
cannot  be  exerted  efficiently  above  the  fourth  or  fifth  rib. 


Chapter  II. 
THE  MOVEMENTS  OF  THE  SPINE. ^ 

The  movements  of  the  spine  are  generally  accepted  as  being  four 
in  number: 

(i)  Flexion  (forward  bending);  (2)  hyperextension  (backward  bend- 
ing); (3)  lateral  bending  (side  bending);  (4)  torsion  or  rotation. 

Although  this  classification  is  usually  found  in  the  books,  it  has  been 
often  recognized  that  torsion  is  in  some  way  associated  with  lateral 
bending.  That  lateral  flexion  probably  does  not  exist  as  a  pure  move- 
ment has  for  some  time  been  recognized  by  some  if  not  all  anatomists, 
and  has  been  taught  for  some  years  by  Professor  Thomas  Dwight.  As 
long  ago  as  1844  Henry  J.  Bigelow  wrote:  "The  principle  of  torsion 
is  illustrated  by  bending  a  flat  blade  of  grass  or  a  flat,  flexible  stick 
in  the  direction  of  its  width.  The  center  immediately  rotates  upon  its 
longitudinal  axis  to  bend  flatwise  in  the  direction  of  its  thickness.  In 
the  same  way  the  spine,  laterally  flexed,  turns  upon  its  vertical  axis  to 
yield  in  its  shortest  or  anteroposterior  diameter."  Occasional  references 
are  found  to  the  association  of  torsion  with  lateral  flexion,  but  no  general 
recognition  of  the  relation  between  the  two  has  existed.  The  move- 
ments of  the  spine  should  therefore  be  considered  as  three  in  number: 
(i)  Flexion;  (2)  extension;  (3)  side  bending,  rotation. 

The  human  spine  is  not  an  extremely  flexible  body  taken  by  itself;  much  of  its 
apparent  flexibility  is  due  to  accessory  movements  between  the  spine  and  the  pelvis 
and  the  head.  An  extreme  forward  flexion,  e.  g.,  in  the  living  model  or  the  intact 
cadaver,  with  the  flexed  head,  the  drooping  shoulders,  and  the  rotated  pelvis, 
implies  a  greater  curve  than  the  spine  itself  possesses.  It  is  surprising  to  see  in  the 
cadaver  how  little  actual  mobility  is  possessed  by  the  three  regions  of  the  spine 
considered  separately,  or  by  the  whole  spine. 

The  application  of  this  is  obvious  without  extended  comment.  If  active  or 
passive  exercises  are  given  which  are  intended  to  take  effect  upon  the  spine  alone 
and  to  be  effective  there,  the  pelvis  must  be  fixed.  If  this  is  not  done,  part  of  the 
muscular  force  is  used  in  displacing  the  pelvis  to  the  opposite  side  to  balance  the 
body,  and  the  movement  becomes  a  general  and  not  a  spinal  one. 

*  R.  W.  Lovett:  "Bos.  Med.  and  Surg.  Jour.,"  June  4,  1900,  Oct.  31,  1901, 
March  17,  1904,  Sept.  28,  1905;  "Amer.  Jour,  of  .Anat.,"  ii,  4,  457. 


24 


THE   MOVEMENTS    OF   THE   SPINE. 


FLEXION  (FORWARD  BENDING) 
Is  a  pure  anteroposterior  movement  without  perceptible  rotation.  It  is  the  most 
evenly  distributed  of  the  spinal  movements,  and  in  extreme  flexion  the  outline  of 
the  tips  of  the  spinous  processes  forms  a  curve  approaching  the  arc  of  a  circle. 
Most  of  the  movement  is  accomplished  in  the  lumbar  region,  which  in  extreme 
flexion  loses  most  of  its  forward  convexity,  but  in  the  observations  made  was  not 
observed  to  become  convex  backward. 


Fig.  i8.— Flexion  of  the  Spine  in  the  Model. 


The  dorsal  region  in  extreme  flexion  becomes  decidedly  more  convex  than  in 
the  upright  position.  The  twelfth  dorsal  vertebra  takes  part  in  flexion  more  as  a 
lumbar  than  as  a  dorsal  vertebra,  and  free  movement  occurs  below  it  and  fairly 
free  movement  between  the  eleventh  and  twelfth  vertebras. 

The  cervical  region  cannot  be  accurately  observed  or  measured  in  the  model. 
In  the  cadaver  it  dries  so  rapidly  that  no  conclusions  can  be  drawn  beyond  the 
statement  that  its  forward  convexity  may  be  obliterated  by  forcible  flexion  •with 
the  hands. 


FLEXION. 


25 


The  most  marked  flexion  of  the  spine  may  be  obtained  by  having  the  model 
sit  cross-legged  and  bend  forward  with  the  chest  between  the  knees.  Extreme 
passive  flexion  with  the  model  lying  on  the  side  is  not  so  great  as  that  obtained  by 
flexion  in  the  cross-legged  position. 

In  flexion  the  distance  of  the  seventh  cervical  vertebra  from  the  sacrum  when 


Fig.  Tg. — Hyperextension  in  the  Model. 
The  head  is  supported  to  secure  steadiness. 


measured  along  the  spinous  processes  is  increased  over  the  same  measurement 
taken  in  standing  or  lying. 

There  seems  to  be  no  constant  difference  in  the  amount  of  flexion  obtained  in 
the  standing  and  sitting  positions,  the  resultant  curve  being  practically  the  same. 
The  chief  difference  between  flexion  in  the  model  and  cadaver  seems  to  consist 
in  a  greater  relative  participation  of  the  dorsal  region  in  flexion  in  the  model. 

Measurements  and  '.racings  of  the  spine  in  the  model  and  in  children  show 
the  relaxed  sitting  position  to  be  one  of  slight  flexion. 


26 


THE   MO\^EMENTS    OF   THE   SPINE. 


HYPEREXTENSION  (BACKWARD  BENDING). 
Hyperextension  is  a  pure  anteroposterior  movement  of  the  spine  without 
perceptible  rotation.  It  is  not  an  evenly  distributed  movement,  but  occurs  almost 
wholly  in  the  lumbar  and  lower  two  dorsal  vertebra.  A  tracing  taken  over  the 
spinous  processes  in  extreme  hyperextension  in  outline  resembles  a  hockey  stick. 
The  dorsal  region  is  but  little  affected,  being  slightly  straightened  by  hyperextension. 
The  bending  reaches  to  about  the  tenth  dorsal,  the  upper  dorsal  region  showing 
but  little  diminution  in  the  physiological  curve,  the  twelfth  dorsal  vertebra,  and,  to  a 
certain  extent,  the  eleventh,  behaving  as  do  the  lumbar  vertebrae  in  hyperextension. 
The  character  of  the  curve  obtained  in  marked  hyperextension  is  practically  the 
same,  whether  it  is  obtained  by  active  or  passive  means,  and  whether  the  model 

lies  on  the  face  or  on  the  side,  or 
stands,  or  sits.  The  column  of  bodies 
alone  shows  the  same  character  and 
- :  :,,  - ,  distribution  of  the  movement  as  does 
the  intact  spine  of  the  cadaver.  The 
illustration  in  this  case  shows  the 
characteristic  rigidity  of  the  dorsal 
region  to  hyperextension. 

In  hyperextension,  the  distance 
from  the  seventh  cervical  vertebra  to 
the  sacrum,  measured  over  the  spin- 
ous processes,  is  decreased  from  the 
same  measurement  taken  in  the  erect 
position. 

LATERAL  FLEXION  (SIDE 
BENDING). 
Lateral  flexion  of  the  spine  ap- 
parently does  not  exist  as  a  pure 
movement,  but  is  to  be  considered 
as  one  part '  of  a  compound  move- 
ment, of  which  twisting  or  rotation 
forms  the  other  part. 

In  describing  this  side  bending  it 
must  be  stated  that  the  character  and  distribution  of  the  movement  vary  widely  ac- 
cording to  the  degree  of  flexion  or  extension  of  the  spine  when  the  side  bending  is 
made.  It  is  also  affected  if  the  spine  is  twisted  before  it  is  bent  to  the  side.  In 
other  words,  there  is  no  one  type  of  spinal  side  bending  as  there  are  types  of  flexion 
and  extension,  but  the  character  and  distribution  of  the  movements  are  wholly  de- 
pendent upon  the  anteroposterior  position  of  the  spine. 

Side  bending  will  first  be  considered  alone  without  regard  to  the  rotation  caused 
by  it,  and  then  the  rotation  accompanying  each  kind  of  side  bending  will  be  de- 
scribed. 

Side  bending  in  lying  on  the  face  shows  a  more  evenly  distributed 
lateral  curve  than  does  that  in  the  erect  position.  The  character  of  the  curve 
does  not  change  essentially  when  the  shoulders  and  pelvis  are  held  and  the  middle 


Fig.  20. — Hypere.xtension  in  thk  Cadaver. 


SIDE    BENDING. 


27 


of  the  trunk  pushed  to  one  side.  The  curve  in  this  position  of  the  spine  is  greater 
in  the  upper  lumbar  vertebrae  and  in  the  two  lower  dorsal  than  in  the  upper  part 
of  the  spine. 

Rotation  Accompanying  Side  Bending  Lying  on  the  Face. — With  the  cadaver 
lying  flat  on  the  face  on  the  table  no  rotation  in  side  bending  was  found  by  v.  Meyer 
and  in  some  experiments  by  Schulthcss;  it  was,  however,  found  by  Benno  Schmidt. 


Fig.  21.— Side  Bending  to  the  Right  in  the  Flexed  Position  of  the  Spine  in  the 

Model. 

A  lateral  curve  convex  to  the  left  is  formed  and  the  vertebral  bodies  have  turned  to  the  left, 

as  shown  by  the  elevation  of  the  left  side  of  the  back. 


With  the  cadaver  lying  prone  on  a  table  the  conditions,  of  course,  are  against  rota- 
tion, the  thorax  and  shoulders  being  to  a  certain  extent  held  against  it  by  the  surface 
of  the  table.  No  perceptible  rotation  is  noted  in  slight  side  bending  under  these 
conditions,  but  the  vertebral  bodies  turn  to  the  concave  side  in  marked  side  bending*- 
In  the  model  lying  flat  on  a  table  one  side  of  the  chest  is  felt  to  press  on  the  table 
harder  than  the  other  in  moderate  side  bending.  The  point  is  not  of  great  impor- 
tance, as  the  practical  problem  is  that  of  the  behavior  of  the  weight-bearing  spine. 


28 


THE   MOVEMENTS   OF   THE   SPINE. 


Side  bending  in  the  flexed  position  of  the  spine  is  a  more  evenly 
distributed  movement  in  which  the  dorsal  region  participates  more  and  the  lumbar 
region  less  than  in  the  erect  position.  The  greatest  deviation  from  a  line  connecting 
the  two  ends  of  the  spine  occurs  at  about  the  eighth  dorsal  vertebra  in  both  cadaver 
and  model.  In  short,  side  bending  occurs  higher  in  the  spine  in  flexion  than  in  any 
other  position,  the  lumbar  region  being  comparatively  locked  against  side  bending 


Fig.  22. — Side  Bending  in  the  Upright  Position  of  the  Model. 
The  movement  is  chiefly  located  at  the  dorsolumbar  junction. 


by  the  flexed  position.  The  more  marked  the  flexed  position,  the  higher  in  the 
spine  is  the  side  bending  localized. 

Rotation  Accompanying  Side  Bending  in  Flexion. — In  the  flexed  position  of 
the  spine,  side  bending  is  accompanied  by  rotation  of  the  bodies  to  the  convexity 
of  the  lateral  curve.  This  rotation  occurs  chiefly  in  the  dorsal  region.  Each 
vertebra  twists  upon  the  one  below  it  in  the  long  axis  of  the  spine;-  the  body  turning 
in  one  direction  and  the  spinous  process  in  the  other. 

In  side  bending  of  the  model  in  the  flexed  position  the  active  movement  is 
accompanied  by  a  much  greater  degree  of  rotation  than  is  the  passive  movement, 


SIDE   BENDING.  29 

the  addition  of  muscular  force  in  this  movement  seeming  to  accentuate  the  element 
of  twisting. 

Side  Bending  in  the  Erect  Position. — In  the  cadaver  the  side  bending 
is  most  marked  below  the  tenth  dorsal  vertebra,  and  the  dorsal  region  shares  but 
slightly.  The  lumbar  region  is  most  affected  in  its  upper  part,  but  shares  to  some 
extent  throughout.  The  whole  dorsal  region  takes  some  part  in  the  movement, 
but  the  dorsal  region,  except  its  lower  part,  compared  to  the  lumbar,  is  resistant 
to  side  bending.  Side  bending  in  the  erect  position  is,  therefore,  largely  a  movement 
occurring  in  the  neighborhood  of  and  below  the  lumbar  dorsal  junction.  It  shows 
the  same  characteristics  in  the  cadaver,  the  model,  and  the  child,  except  that  in  the 
two  last  named  the  dorsal  region  takes  a  greater  relative  part  than  in  the  cadaver 


Fig.  23. — Side  Bending  in  the  Upright  Position  of  the  Cadaver,  showing  the  Same 
Characteristics  as  in  the  Model. 

The  column  of  vertebral  bodies  alone  behaves  in  side  bending  in  all  positions  in 
the  same  way  as  do  the  intact  cadaver,  the  model,  and  the  child. 

Rotation  Accompanying  Side  Bending  in  the  Erect  Position. — In  this  position 
side  bending  causes  the  rotation  of  the  bodies  of  the  vertebrae  to  the  concave  side 
of  the  lateral  curve.  It  occurs  lower  dowTi  in  the  spine  than  in  the  flexed  position. 
The  dorsal  region  participates  less  and  the  lumbar  region  more  in  the  movement. 

Side  Bending  in  the  Hyperextended  Position  of  the  Spine. —  With 
the  spine  of  the  cadaver,  model,  or  child  hyperextended,  the  side  bending  becomes 
a  sharply  limited  movement,  localized  low  down  in  the  spine  and  occurring  almost 
whoUy  below  the  eleventh  dorsal  vertebra,  becoming,  therefore,  essentially  a  lumbar 
movement.  The  dorsal  region  bends  as  a  whole  upon  the  lumbar  and  rocks  over 
to  the  side  practically  unchanged,  being  locked  against  side  bending  by  the  hyper- 
extended position.     Side  bending,  therefore,  is  situated  highest  in  the  flexed  position, 


30  THE   MOVEMENTS    OF   THE    SPIXE. 

lower  down  in  the  erect  position,  and  lowest  in  hyperextcnsion  in  the  model,  cadaver, 
and  child.  In  side  bending  in  all  positions  the  twelfth  dorsal  vertebra  behaves 
as  a  lumbar,  not  as  a  dorsal,  vertebra. 

Rotation  Accompanying  Side  Bending  in  the  Hyperextended  Position. — This 
is  a  sharply  limited  movement  occurring  in  the  lumbar  region  including  the  twelfth 
dorsal  as  functionally  a  lumbar  vertebra.  The  thoxax  rocks  over  to  the  side  un- 
changed, and  the  rotation  of  the  bodies  is  to  the  concave  side  of  the  lateral  curve. 


Fig.  24. — Side   Bending   to   the    Right   in   the    Hyperextended   Position    of    the 

Spine  in  the  Model. 
The  head  is  supported  to  secure  steadiness. 

The  rotation  accompanying  this  type  of  side  bending  is  essentially  a  different  kind 
•of  motion  from  that  occurring  in  side  bending  in  flexion,  as  it  is  less  distributed 
through  the  spine  and  is  of  a  more  decided  character.  The  column  of  bodies  alone 
rotates  in  essentially  the  same  way  as  does  the  intact  spine  in  side  bending  in  the 
erect  and  hyperextended  position. 

Rotation  accompanying  side  bending  is,  therefore,  of  a  different  type  in  the 
flexed  position  of  the  spine  from  what  it  is  in  the  erect  or  hyperextended  position. 


ROTATION. 


31 


In  the  flexed  position  the  lumbar  region  is  locked  against  side  bending,  and  the 
side  bend  and  rotation  occur  chiefly  in  the  dorsal  region  and  conform  to  the  dorsal 
type,  i.  e.,  the  bodies  turn  to  the  convexity  of  the  lateral  curve.  In  side  bending 
occurring  in  the  erect  or  hyperextended  position,  however,  the  lumbar  region  and 


Fig.  25.— Side  Bending  to  the  Right  in 
hvperextension  in  the  colu.mn  of 
Vertebral  Bodies. 

The  same  characteristics  are  shown  as  in 
the  previous  figure. 


Fig.  26. — Side  Bending  to  the  Right  in 
the  Hyperextended  Position  of 
the  Spine  in  the  Cadaver. 

The  movement  occurs  chiefly  at  and  be- 
low the  dorsolumbar  junction,  and  the 
bodies  of  the  vertebrae  turn  to  the  right, 
as  shown  by  the  pins.  The  lateral 
curve  is  convex  to  the  left. 


lower  dorsal  region  is  the  chief  seat  of  the  movement,  and -as  in  all  side  bends 
in  the  lumbar  region  the  bodies  of  the  vertebrae  turn  to  the  concavity  of  the  lateral 
curve. 


ROTATION. 

Rotation  or  twisting  of  the  spine  is  to  be  considered  as  part  of  a  compound 
movement  of  which  side  bending  forms  the  other  part.  For  purposes  of  simplicity 
the  rotation  element  of  the  movement  will  be  considered  by  itself.  Under  ordinary 
conditions  it  is  essentially  a  movement  of  the  dorsal  and  cervical  regions  in  which 
the  lumbar  vertebrae  take  but  little  part  except  in  hyperextension  and  with  the  use 
of  traction.  The  lumbar  vertebral  region  possesses  some  power  of  rotation,  as  has 
been  generally  observed. 

Rotation  in  the  Erect  Position. — Rotation  is  freest  in  the  erect  position 
and  is  situated  in  the  cervical  and  dorsal  regions,  reaching  its  maximum  at  the  top 
of  the  cervical  column  and  extending  down  the  spine  to  the  lower  dorsal  region. 


32  THE   MO\TEMENTS    OF  THE   SPINE. 

where  it  disappears.  With  very  forcible  rotation  appHed  to  the  top  of  the  column 
in  the  cadaver,  the  first  and  even  the  second  lumbar  vertebra;  may  be  rotated. 
The  rotation  in  this  position  is  accompanied  by  a  side  bend  of  the  rotated  region 
away  from  the  side  to  which  the  bodies  of  the  vertebrae  turn.  If  the  rotation  is 
to  the  right,  it  is  accompanied  by  a  bend  convex  to  the  left  and  vice  versi.  In  the 
model  an  active  rotation  to  the  right  is  accompanied  by  a  displacement  of  the  trimk 
to  the  left  side  and  vice  versa.     If  traction  is   applied  to  the  head  of  the  erect 


Fig.  27.— Rotation  of  the  Model,  Face  to  the  Right,   Causing  a  Dorsal  Lateral 
Curve  Convex  to  the  Left  and  a  Displacement  of  the  Trunk  to  the  Left. 

cadaver,  forcible  twisting  of  the  head  results  in  rotation  of  the  lumbar  vertebrae 
including  the  fourth. 

Rotation  in  the  Flexed  Position. — Rotation  in  the  flexed  position  of 
the  spine  occurs  chiefly  in  the  cervical  and  upper  dorsal  spine,  the  lower  dorsal 
and  lumbar  region  seeming  locked  against  rotating  forces  by  the  flexed  position. 
The  more  extreme  the  flexion  the  more  markedly  in  cadaver,  model,  and  child  is 
the  rotation  restricted  to  the  cervical  and  upper  dorsal  spine. 


ROTATION. 


33 


Rotation  in  the  Hyperextended  Position. — In  hyperextended  positions 
rotation  with  moderate  manual  force  occurs  as  a  twisting  of  the  whole  thorax  on 
an  axis  in  the  dorsolumbar  region,  the  upper  and  middorsal  regions  apparently 
being  locked  against  rotation  by  hyperextension.  The  site  of  rotating  movement 
in  this  position  is,  therefore,  in  the  one  or  two  vertebrae  above  and  the  one  or  two 
vertebrae  below  the  dorsolumbar  junction. 

Rotation,  therefore,  is  located  high  in  flexed  positions,  lower  in  erect  positions, 
and  is  situated  lowest  and  is  of  a  different  type,  being  more  sharply  localized,  in 
hyperextended  positions.  In  the  column  of  bodies  alone  rotation  possesses  the 
same  characters  as  does  the  intact  column. 


Fig.  28.— Rotation  of  the  Spine  of  the 
Cadaver,  Face  to  the  Right  in  the 
Flexed  Position  of  the  Spine. 

The  movement  is  seen  to  be  located  in  the 
upper  part  of  the  column  by  the  devi- 
ation of  the  pins. 


Fig.  29. — Rot.ation  of  the  Spine  of  the 
Cadaver,  Face  to  the  Right,  in 
the  Hyperextended  Position. 

The  movement  is  seen  to  occur  in  the  lower 
part  of  the  spine  by  the  rotation  of  the 
pins. 


Side  Bends  Accompanying  Rotation. — A  lateral  deviation  of  the  spine  accom- 
panies all  rotations.  It  is  situated  at  the  site  of  the  rotation  and  is  convex  to  the 
right  when  the  rotation  is  to  the  left  and  vice  versa.  In  the  erect  position  rotation 
causes  a  marked  side  curve  in  the  dorsal  region. 

Reasons  for  Torsion. — It  is  obvious  from  these  experiments  that  there 
must  be  some  fundamental  reason  for  the  constant  occurrence  of  one  type  of  tor- 
sion for  side  bendings  in  flexion  and  the  occurrence  of  another  type  in  extension, 
as  well  as  for  the  constant  association  of  torsion  with  side  bending.  The  vertebral 
column  is  a  flexible  rod  capable  of  bearing  great  weight.  It  is  not  equally  flexible 
in  all  directions,  but  it  is,  of  course,  capable  of  some  movement  in  all  planes,  and, 
as  such,  should  come  under  the  control  of  the  laws  governing  flexible  rods  in  gen- 
3 


34  THE   TiIOVEMENTS    OF   THE   SPINE. 

eral.  The  extent  of  any  of  the  movements  of  the  spine  is,  of  course,  greatly  influ- 
enced by  the  shape  of  the  vertebral  bodies,  the  curves  of  the  spine,  the  character  of 
the  articular  processes,  the  resistance  of  the  ligaments,  and  the  relative  strength 
of  the  muscles. 

From  the  mechanical  point  of  view,  torsion  results  from  any  motion  of  a  straight 
flexible  rod  in  which  all  the  particles  do  not  move  in  parallel  planes.  Consequently, 
if  such  a  rod  is  bent  in  two  planes  at  the  same  time,  torsion  must  inevitably  occur. 
The  vertebral  column  is  not  a  straight  flexible  rod,  but  one  bent  in  the  anteropos- 
terior plane  by  a  series  of  gentle  curves;  side  bending  must  therefore  inevitably 
lead  to  torsion,  because  it  means  bending  in  two  planes.  Nor  does  the  fact  that  the 
intervertebral  discs  permit  motion  in  all  directions  affect  the  question,  because 
from  a  mechanical  point  of  view  the  vertebral  column  behaves  in  general  as  it  would 
if  it  were  a  homogeneous  flexible  rod,  and  one  does  not  have  to  wait  for  torsion  to 
occur  until  the  intervertebral  discs  are  compressed  and  the  edges  of  the  vertebrse 
come  into  contact,  for,  from  a  mechanical  point  of  view,  the  torsion  begins  with 
the  beginning  of  the  side  bending.  It  therefore  seems  very  unlikely  that  pure 
lateral  flexion  of  the  spine  ever  exists. 

A  strip  of  sponge  rubber,  half  an  inch  in  diameter  and  fourteen  inches  long, 
rotates  in  the  same  way  that  the  vertebral  column  does  in  the  same  position.  A 
lateral  curvature,  in  what  corresponds  to  the  flexed  position  of  the  spine,  may  be 
produced  in  the  rubber  strip  following  the  same  rule  of  rotation  seen  in  life;  that  is, 
the  front  of  the  rod  turns  toward  the  convexity  of  the  lateral  curve.  An  artificial 
lateral  curvature  in  the  rubber  strip,  made  in  what  corresponds  to  the  extended 
position  of  the  spine,  results  in  a  reverse  rotation  to  that  from  the  rotation  of  the 
flexed  position.  A  piece  of  rattan,  a  piece  of  rubber  tubing,  a  strip  of  sponge 
rubber,  round  or  square,  the  backbone  of  a  fish,  or  the  backbone  of  a  cat,  behave 
all  in  the  same  way,  and  rotate  in  the  same  direction  as  does  the  human  spine. 

Articular  Processes. — Although  it  is  easy  to  understand  that  the  column 
of  vertebral  bodies  by  itself  might  easily  behave  as  a  flexible  rod,  yet  the  articular 
processes  cannot  be  left  out  of  account.  They  must  be  an  important  factor  in 
determining  torsion,  and  they  must  do  one  of  two  things.  Either  they  must  fall 
in  with  the  behavior  of  the  flexible  column  of  bodies  and  serve  to  carry  out  the 
rotation  which  would  occur  without  them,  or  they  must  obstruct  or  reverse  the 
rotation  which  would  occur  in  the  column  of  vertebral  bodies  alone.  Experiments 
seem  to  show  that  the  articular  processes  merely  serve  to  accentuate  the  same 
rotation  that  would  be  present  if  the  column  of  vertebral  bodies  were  by  itself. 

Two  vertebral  columns,  which  had  been  previously  used  and  which  had  con- 
formed to  the  usual  rule,  were  prepared  for  experiment  by  removing  the  column  of 
bodies  by  cutting  through  the  pedicles.  The  columns  experimented  upon  then 
consisted  of  laminae  and  articular  processes  with  their  ligaments.  The  ribs  were 
not  removed  from  these  columns.  These  could  no  longer  be  regarded  as  flexible 
rods,  and  were  only  anatomical  preparations  to  demonstrate  just  what  part  in 
rotation  the  articular  processes  would  play  if  left  to  themselves. 

Each  of  these  spines  was  then  placed  in  a  vise  and  pulled  to  the  side.  When 
the  spine  was  hyperextended  and  pulled  to  the  left,  rotation  occurred  of  the  same 
type  as  in  the  intact  column  in  the  similar  position,  a  rotation  of  the  ribs  backward 
on  the  side  of  the  concavity.  That  is,  the  articular  processes  alone  do  the  same 
thing  in  side  bending  in  the  extended  position  that  the  intact  column  does. 

In  side  bending  from  the  flexed  position,  however,  the  spine  without  bodies 


MOVEMENTS   BY   REGIONS.  35 

rotates  in  just  the  reverse  direction  from  that  of  the  intact  spine  in  the  same  position, 
the  rotation  of  the  ribs  being  backward  on  the  side  of  the  concavity.  This,  of 
course,  suggests  that  in  side  bending  in  the  extended  position  the  articular  processes 
are  active,  but  that  in  flexed  positions  they  are  not. 

To  see  if  this  state  of  affairs  really  existed,  a  spine  which  had  been  used  and 
which  had  followed  the  rule  was  sawed  longitudinally  in  such  a  way  as  to  divide 
each  articular  process  in  the  long  axis  of  the  spine.  The  portion  on  the  outer  side 
of  this  cleft  was  removed,  giving  a  view  of.  each  articulation.  The  spine  was  then 
flexed,  and  it  was  found  that  as  moderate  flexion  began  the  articular  joint  surfaces 
in  the  dorsal  region,  which  was  the  particular  field  observed,  began  to  separate,  and 
in  extreme  flexion  were  separated  by  an  interval  of  perhaps  one  thirty-second  of  an 
inch.  As  the  spine  was  extended  they  seemed  to  come  into  close  contact  at  about 
the  point  where  the  flexion  rotation  changes  to  the  extension  rotation.  In  marked 
extension  they  were  firmly  in  contact. 

The  conclusion  from  this  is  that  the  column  of  vertebral  bodies  alone,  without 
articular  processes,  rotates  in  just  the  same  way  in  side  bending,  in  flexion,  and 
extension  that  the  column  does  with  articular  processes  present;  that  in  flexion 
they  are  not  sufficiently  in  contact  to  determine  the  rotation,  but  that  in  extension 
they  are  in  contact,  and  are  the  active  factors  in  determining  the  rotation  which 
occurs  in  extension.  That  rotation  is,  however,  in  the  same  direction  that  it  would 
be  if  the  column  consisted  of  vertebral  bodies  alone.  They  apparently  serve  to 
accentuate  and  carry  out  the  behavior  of  a  flexible  rod  in  general,  although  they 
undoubtedly  aid  in  preventing  pure  lateral  flexion  of  the  spine. 


:he  cervical  regioi 

Flexion. — It  is  possible  to  straighten  the  anterior  physiological  curve.  Much 
of  the  apparent  forward  flexion  in  the  cervical  region  in  life  is  evidently  due  to  the 
motion  between  the  occiput  and  the  atlas. 

Hyperextension. — The  physiological  curve  can  be  increased  to  a  certain  extent. 

Side  Bending. — Side  bending  is  uniformly  distributed  throughout  the  cer- 
vical region  and  is  accompanied  by  rotation  of  the  bodies  of  the  vertebrae  to  the 
concavity  of  the  lateral  curve,  as  in  the  lumbar  region.  Rotation  and  side  bending 
seem  always  associated. 

Rotation. — Rotation  is  extremely  free  between  the  first  and  second  cervical 
vertebras,  but  for  the  rest  of  the  region  it  is  limited.  Rotation  is  accompanied  by  a 
side  bend  convex  to  the  side  opposite  to  which  the  bodies  of  the  vertebra  turn; 
that  is,  in  a  right  rotation  the  curve  is  convex  to  the  left. 

DORSAL  REGION. 

The  dorsal  region  is  the  least  mobile  part  of  the  spine  as  a  whole.  The  twelfth 
dorsal  vertebra  from  the  point  of  view  of  function  must  be  regarded  as  a  lumbar 
vertebra  and  not  as  part  of  the  dorsal  region. 

Flexion. — The  dorsal  spine  already  convex  backward  can  be  made  somewhat 
more  convex  by  forward  bending,  but  the  extent  of  the  movement  is  not  great  and 
by  no  means  comparable  to  the  same  movement  in  the  lumbar  region. 

Hyperextension. — Hyperextension  is  a  motion  of  very  slight  extent  in  the 
dorsal  region.  It  consists  of  a  diminution  of  the  backward  convexity  and  is  most 
noticeable  in  the  lower  half  of  the  region. 


36  THE   MOVEMENTS   OF   THE   SPINE. 

Side  Bending. — Side  bending  of  the  dorsal  region  is  a  fairly  evenly  distributed 
movement  of  slight  extent,  presenting  an  even  curve  which  is  greatest  in  the  mid- 
dorsal  region.  It  is  freest  in  the  erect  position  or  lying  on  the  face.  It  occurs 
less  markedly  in  flexed  positions  and  least  in  hyperextension.  Side  bending  here 
is  always  accompanied  by  rotation  of  the  bodies  of  the  vertebrae  to  the  convex  side 
of  the  lateral  curve.  With  the  upper  end  of  the  column  free  the  rotation  occurring 
in  flexion  is  very  marked  in  cadavers  from  which  the  sternum  has  been  removed. 

Rotation  is  the  most  marked  of  dorsal  movements.  It  reaches  its  greatest 
extent  in  the  upper  dorsal  vertebrae  and  diminishes  toward  the  lower  end  of  the 
region.  In  a  rotation  of  moderate  force  in  the  upright  position  it  extends  to  and 
includes  the  seventh  or  eighth  dorsal  vertebra.  Rotation  of  this  region  is  less  in 
flexion  than  in  the  erect  position  and  does  not  extend  so  far  down.  In  hyperexten- 
sion it  is  much  limited  and  in  extreme  hyperextension  in  the  cadaver  the  dorsal 
rotation  movement  seems  to  be  obliterated. 

Rotation  is  accompanied  always  by  side  bending,  the  lateral  curve  being  convex 
to  the  side  away  from  which  the  bodies  of  the  vertebrae  turn.  In  a  rotation  of  the 
top  of  the  column  to  the  left  the  lateral  curve  is  to  the  right  and  vice  versa. 

The  practical  points  to  be  borne  in  mind  in  the  study  of  the  dorsal  region  are 
the  facts  that  rotation  is  freer  than  side  bending,  that  hyperextension  is  extremely 
limited,  and  that  the  rotation  of  the  vertebrae  in  side  bending  in  the  dorsal  region  is 
always  toward  the  convexity  of  the  lateral  curve. 


LUMBAR  REGION. 

Flexion  in  the  lumbar  region  is  a  movement  of  much  freedom,  but  the  physi- 
ological curve  in  the  adult  cadaver  has  not  been  obliterated  in  any  case  observed 
by  the  writer. 

Hyperextension  as  a  general  spinal  movement  is  essentially  a  lumbar  motion 
and  in  that  region  is  an  evenly  distributed  bend. 

Side  bending  is  a  free  movement  in  the  lumbar  region  and  forms  in  the 
erect  position  a  very  evenly  distributed  curve.  It  varies  markedly  in  the  flexed, 
erect,  and  hyperextended  positions.  It  is  greatest  in  the  erect  position  and  least 
in  extreme  flexion.  ■"- 

The  rotation  accompanying  side  bending  in  the  lumbar  spine  is  always  with  the 
bodies  turning  to  the  concavity  of  the  lateral  curve;  in  a  bend  convex  to  the  left 
the  vertebral  bodies  turn  to  the  right.  This  is  to  be  contrasted  with  the  opposite 
rotation  occurring  in  side  bending  in  the  dorsal  region.     "•*. 

Rotation  in  the  lumbar  region  is  extremely  limited.  It  is  diminished  by 
extreme  hyperextension  and  is  least  or  absent  in  extreme  flexion.  Under  natural 
conditions  the  rotation  is  greatest  in  the  erect  position,  but  by  the  addition  of  trac- 
tion in  that  position  it  is  decidedly  increased. 

The  lumbar  region  possesses  marked  mobility  in  flexion,  hyperextension,  and 
side  bending,  and  but  little  in  rotation.  Side  bending  is  more  free  than  rotation 
in  contradistinction  to  the  relation  of  these  two  movements  in  the  dorsal  region. 
The  rotation  whiqh  accompanies  side  bending  is  also  the  opposite  of  that  occurring  in 
the  dorsal  region.  In  the  lumbar  region  the  bodies  turn  toward  the  concavity  of 
the  lateral  curve,  i.  e.,  in  a  bend  convex  to  the  left  the  bodies  tuin  to  the  right. 
The  lumbar  region  must  be  considered  in  function  as  including  the  twelfth  dorsal 
vertebra. 


CONCLUSIONS   AS   TO   MOVEMENTS.  37 

CERTAIN  CONCLUSIONS  AS  TO  THE  MOVEMENTS  OF  THE  THREE 
REGIONS  OF  THE  SPINE. 

1.  In  the  lumbar  region  flexion  diminishes  mobility  in  the  direction  of  side 
bending  and  rotation,  and  extreme  flexion  seems  to  lock  the  lumbar  spine  against 
these  movements. 

2.  In  the  dorsal  region  hyperextension  diminishes  mobility  in  the  direction  of 
side  bending  and  rotation.  Extreme  hyperextension  seems  to  lock  the  dorsal 
spine  against  these  movements. 

3.  In  flexion  of  the  vs^hole  spine  side  bending  is  accompanied  by  rotation  of 
the  vertebral  bodies  to  the  convexitjf  of  the  lateral  curve,  the  characteristic  of  the 
dorsal  region. 

4.  In  the  erect  position  and  in  hyperextension  of  the  whole  spine  side  bending 
is  accompanied  by  rotation  of  the  vertebral  bodies  to  the  concavity  of  the  lateral 
curve,  the  characteristic  of  the  lumbar  region.  ~ 

5.  The  dorsal  region  rotates  more  easily  than  it  bends  to  the  side,  whereas 
the  lumbar  region  bends  to  the  side  more  easily  than  it  rotates. 

6.  Rotation  in  the  dorsal  region  is  accompanied  by  a  lateral  curve,  the  con- 
vexity of  which  is  opposite  to  the  side  to  which  the  bodies  of  the  vertebrae  rotate. 

7.  The  column  of  vertebral  bodies  obeys  in  flexion,  hyperextension,  side 
bending,  and  rotation,  and  in  the  combinations  of  them  the  same  rules  which 
govern  the  intact  spine,  a  fact  of  much  significance  in  connection  with  the  rotation 
theories  of  v.  Meyer  and  Albert. 


Chapter  III. 

MECHANISM  OF  SCOLIOSIS. 

Elasticity  of  Vertebrae  and  Intervertebral  Discs. — The  spinal 
column  is  capable  of  some  movement  in  all  directions.  The  elasticity 
of  the  intervertebral  discs  is  such  that  the  ball-and-socket  joint  between 
each  two  vertebrae  allows  motion  between  them  in  any  plane  or  direc- 
tion until  limited  by  bony  contact  and  ligamentous  or  muscular  tension. 
It  also  allows  rotation  to  occur  between  two  separate  vertebrae  in  an  ap- 
proximately horizontal  plane.  Bone  is  slightly  compressible,  but  this  is 
not  a  factor  of  importance  in  contributing  to  vertebral  flexibility. 

Lange^  has  experimented  with  vertebrse  at  different  ages,  and  has  found  that 
their  resiliency  when  released  from  pressure  is  greater  in  adult  life  than  in  childhood, 
but  in  the  former  very  much  less  compression  is  possible.  He  has  further  shown 
that  cohesiveness  of  a  vertebra  is  greatest  in  children,  less  in  adults,  and  still  less 
with  advancing  age.  In  other  words,  a  child's  vertebra  may  be  more  easily  com- 
pressed but  less  easily  torn  apart  than  that  of  an  adult. 

Fessler  gives  the  elasticity  of  intervertebral  discs  as  perfect,  inasmuch  as  they 
resume  their  original  form  after  compression  and  they  are  exceedingly  tough  and 
strong.  Fracture  of  the  vertebral  column  through  a  disc  will  occur  only  \mder 
a  pull  exerted  in  the  long  axis  of  the  spine.  Under  such  conditions  the  separation 
in  the  cervical  and  lumbar  regions  will  occur  through  the  discs,  starting  at  the 
posterior  part  and  overcoming  last  the  resistance  in  the  anterior  common  ligament. 
In  the  dorsal  region,  on  account  of  the  natural  kyphosis  of  that  part  of  the  spine, 
the  anterior  ligament  wUl  be  the  first  to  give  way. 

In  childhood  the  vertebrae  are  largely  cartilaginous,  and  the  increas- 
ing proportion  of  bone,  along  with  the  diminishing  proportion  of  car- 
tilage, causes  a  decrease  of  flexibility  from  youth  to  adult  age,  aside 
from  the  fact  that  the  flexibility  of  all  joints  is  greater  in  youth.  With 
old  age  the  capability  of  movement  of  the  spine  is  greatly  lessened  on 
account  of  the  atrophy  of  the  intervertebral  discs. 

Loss  of  Height  During  the  Day. — It  has  been  noticed  that 
measurement  of  the  height  of  the  same  individual  taken  in  the  morn- 
ing and  in  the  evening  shows  a  decrease  in  the  total  height  of  the  body 
of  from  I  to  2  cm.  during  the  day. 

^  "Zeitsch.  f.  orth.  Chir.,"  x,  1902,  47. 


UPRIGHT   POSITION.  39 

Story  found  an  average  loss  in  height  of  1.452  cm.  during  the  day; 
1.342  cm.  of  this  loss  occurred  in  the  spine,  the  rest  below  the  trunk. 
This  point  is  of  practical  importance  when  exact  measurement  of  the 
height  is  to  be  taken,  as  in  individual  cases  the  loss  is  much  more  than 
the  average  mentioned.^ 

This  has  been  variously  attributed  to  an  increase  of  the  normal 
physiological  curves  of  the  spine  through  fatigue,  and  to  compression 
of  the  intervertebral  discs  due  to  the  continuous  weight  supported  by 
the  spinal  column  in  the  upright  position,  and  also  to  a  general  settling 
down  of  the  whole  body.  Some  observations  not  yet  published,  made 
by  students  of  the  Boston  Normal  School  of  Gymnastics,  show  no 
increase  of  physiological  curves. 

Upright  Position. — The  spine,  it  has  been  seen,  is  a  curved,  seg- 
mented, weight-bearing  rod  resting  in  unstable  equilibrium  on  the  sac- 
rum, which  forms  part  of  a  bony  ring  balanced  on  the  hip-joints.  Its 
upright  position  is  due  to  a  sense  of  balance  possessed  by  the  living  in- 
dividual,, for  in  the  cadaver  in  the  upright  position  no  such  erect  attitude 
obtains  on  account  of  the  absence  of  muscular  action.  This  sense  of 
balance  expresses  itself  in  a  muscular  contraction  by  which  the  living 
individual  keeps  his  center  of  gravity  over  the  center  of  support.  It  is 
reflex  and  instinctive,  and  the  individual  has  no  knowledge  of  it  as  such 
any  more  than  he  has  of  the  mechanism  of  breathing  or  swallowing. 

The  living  individual,  therefore,  keeps  his  spine  erect,  first,  because 
he  has  a  sense  of  balance,  and,  second,  because  he  has  a  muscular  sys- 
tem which  responds  to  his  instinctive  nervous  impulses  and  carries 
out  of  itself  the  necessary  muscular  adjustment  which  is  too  complicated 
to  describe  or  formulate.  This  instinctive  sense  of  balance  and  equilib- 
rium must  be  regarded  as  an  attribute  of  the  erect  living  individual, 
and  must  be  given  a  place  in  the  study  of  scoliosis.  It  is  effective  in 
two  directions: 

1.  The  erect  person  instinctively  strives  to  keep  the  head  approxi- 
mately over  the  middle  of  the  pelvis,  that  is,  in  the  sagittal  or  antero- 
posterior median  plane  of  the  body. 

2.  The  erect  person  instinctively  strives  to  keep  the  eyes  straight 
to  the  front  and  the  shoulder -girdle  approximately  in  the  same  plane 
as  the  pelvis,  i.  e.,  in  the  frontal  or  lateral  plane  of  the  body. 

This  adjustment,  especially  the  element  which  seeks  to  keep  the' 
shoulder-girdle   in   the  same  plane  as   the  pelvis  while  disturbances 

'  T.  A.  Story:   "Amer.  Jour,  of  Orth.  Sur.,"  i,  2,  page  234. 


40 


MECHANISM   OF   SCOLIOSIS. 


%4., 


twisting  the  column  below  are  taking  place,  is  an  important  factor 
in  explaining  the  phenomena  of  scoliosis,  as  will  be  seen  later. 

The  body  is,  however,  not  a  firm  mass,  but  consists  of  segments 
joined  together,  one  segment  resting  upon  the  other,  and  firmly  con- 
nected by  a  tube  made  up  of  muscles,  fasciae,  and  integument.^  Since 
to  maintain  the  erect  attitude  the  line  of  gravity  must  pass  through 
the  base  of  support,  so  in  all  positions  in  which  balance  is  maintained 
there  is  a  constant  equilibration  by  means  of  shifting  segments. 

If  the  pelvi§  of  a  cadaver  is  raised  on  the.  right  side  and  the  upright 

spine  is  left  free  to  move,  the 
top  of  the  column  falls  to  the 
left  and  the  spine  is  curved  con- 
vex to  the  right.  This  is  the 
position  induced  by  gravity. 
If,  on  the  other  hand,  the  right 
side  of  the  pelvis  of  a  living 
model  is  raised  and  the  upright 
spine  is  left  free  to  move,  the 
top  of  the  column  remains  up- 
right and  the  spine  is  curved  in 
the  opposite  direction,  convex 
to  the  left.  This  is  the  position 
of  balance  overcoming  the  posi- 
tion induced  by  gravity.  The 
sense  of  equilibrium  has  worked 
against  the  force  of  gravity  and 
has  reversed  the  position  nat- 
ural to  the  cadaver.  Anything 
which  causes  any  part  of  the 
body  to  be  held  in  an  asym- 
metrical position  will  cause  a 
lateral  deviation  of  some  part 
of  the  spine,  because  a  straight,  erect  spine  in  the  sagittal  plane  is  pos- 
sible only  when  the  person  stands  on  both  feet  or  sits  erect  with  the  arms 
in  similar 'positions  and  the  head  pointing  straight  ahead.  Every  step, 
every  raising  of  the  arm,  every  tilting  of  the  head  is  accompanied  by 
a  deviation  of  the  spine  from  the  median  plane  of  the  body:  in  other 
words,  by  a  temporary  lateral  curve  which  disappears  as  the  symmetrical 
attitude  is  resumed. 


Fig.  30. — The  Right  Side  of  the  Pelvis 
OF  THE  Cadaver  is  Raised  and  the 
Upper  Part  of  the  Spine  Falls  to 
the  Left,  Making  a  Lateral  Curve 
Convex  to  the  Right. 


^Feiss:    "Amer.  Jour,  of  Orth.  Sur.,"  iv,  i,  37. 


PLASTICITY   OF   BONE. 


41 


If  there  is  a  visual  error  that  causes  the  head  to  be  held  obliquely; 
if  there  is  a  short  leg  causing  the  pelvis  to  be  no  longer  horizontal 
but  slanted;  if  the  muscles  of  one  side  of  the  back  are  paralyzed,  there 
must  be  a  constant  compensation  or  curve  which  will  still  enable  the 
center  of  gravity  to  be  held  over  the  center  of  support.  Wlien  such  a 
curved  position  becomes  habitual  for  any  of  the  reasons  given  or  for 


Fig.  31. — The  Right  Side  of  the  Pelvis  of  the  Model  is  Raised  and  the  Upper 
Part  of  the  Spine  is  Carried  to  the  Right,  Making  a  Lateral  Curve  Convex 
TO  THE  Left.     (Cf.  Fig.  41.) 


Other  reasons,  there  exists  in  the  adaptive  character  of  bone  a  reason 
why  this  constantly  assumed  malposition  should  make  a  change  in  the 
shape  of  the  bones  in  a  growing  child  and  that  these  changes  should 
become  fixed. 

Plasticity  of  Bone. — The  adaptability  of  bone  to  pressure  has  been 


42 


MECHANISM   OF   SCOLIOSIS. 


recognized  in  general  and  has  been  formulated  and  forms  one  aspect  of 
what  is  often  spoken  of  as  Wolff's^  law,  which  may  be  expressed  briefly 
as  follows:  "  Every  change  in  the  formation  and  function  of  the  bones, 
or  of  their  function  alone,  is  followed  by  certain  definite  changes  in  their 
internal  architecture  and  equally  definite  secon- 
dary alterations  of  their  external  conformation 
in  accordance  with  mathematical  laws." 

The  phenomena  of  lateral  curvature  have 
become  somewhat  more  comprehensible  since 
we  have  understood  that  bone  is  a  plastic  and 
adaptable  structure  adapting  itself  to  the  de- 
mands on  it,  following  in  its  growth  the  lines 
of  least  resistance,  and  in  children  susceptible 
to  great  changes  in  shape  from  abnormal  con- 
ditions. As  an  instance  of  this  may  be  men- 
tioned the  great  distortion  of  the  shape  of  the 
bones  in  the  Chinese  lady's  foot  produced  by 
iDandaging.  It  is  not  necessar}'-  to  multiply 
them,  for  we  have  direct  experimental  proof 
of  the  case  in  question  in  the  experiments  of 
WuUstein  and  Arnd. 


Fig.  32.  —  Experimen- 
tal Scoliosis  in  a 
Rabbit  Produced 
BY  Cutting  the 
Erector  Spin^e 
Muscles. — {Arnd.) 


Fig.  33.— Fifth  Lu.mbar  Vertebra   fro.m   Experi.mental 
Scoliosis  in  Rabbit. — (Arnd.) 


Wullstein'  showed,  by  bandaging  young  dogs  for  months  in  posi- 
tions with  the  spine  bent  laterally  in  some  and  in  others  bent  backward, 

'Wolff:  "Das  Gesetz  der  Transformation  der  Knochen,"  Berlin,  1892; 
Freiberg:  "Am.  Jour.  Med.  Sci.,"  Dec,  1902;  "Animal  Mechanics,"  by  Sir 
Charles  Bell  and  J.  Wyman,  Cambridge,  1902. 

^"Zeitsch.  f.  orth.   Chir.,"   x,  2. 


TYPES  OF  LATERAL  CURVATURE. 


43 


not  be 
section 


removed 
of  these 


that  a  permanent  bony  deformity  occurred  which  could 
by  traction  in  the  length  of  the  spine  after  death.  A 
columns  showed  wedge-shaped  de- 
formity of  the  vertebras  with  a  "lip- 
ping" of  the  borders  of  the  vertebrae 
on  the  concave  side  of  the  curve,  the 
trabeculas  being  thickened  on  the  side 
of  the  bodies  toward  the  concavity. 
The  changes  were  more  marked  at 
the  articular  ends  of  the  bones  than 
in  the  middle  of  them. 

Arndt^  produced  similar  permanent 
curves  characterized  by  bony  deformity 
and  marked  rotation  in  rabbits  by  ex- 
tirpation of  the  erector  trunci  muscles. 
They  showed,  as  in  WuUstein's  experi- 
ments, that  the  changes  are  greatest  at 
the  articular  ends  of  the  bodies,  and 
the  epiphyseal  plates  in  the  most  de- 
formed vertebrae  clearly  overlap  the 
sides  of  the  body.  There  are  of  course 
many  other  causes  of  lateral  curvature 
which  will  be  mentioned,  such  as  in- 
equalities of  structure  on  the  two  sides, 
congenital  malformation,  and  the  like. 


TYPES  OF  LATERAL  CURVATURE. 

There  are  two  types  of  malposition 
in  lateral  curvature:  in  one,  the  posi- 
tion is  that  which  any  normal  spine  may 
assume;  in  the  second,  the  position  is 
one  that  the  normal  spine  cannot  as- 
sume, a  position  which  implies  a  change 
in  the  shape  of  the  bones. 

The  first  is  due  to  the  adjustment 
necessary  to  keep  the  balance  of  the 
spine  in  the  presence  of  one  of  the  dis- 
turbing causes  mentioned.  If  this  be- 
comes habitual,  it  results  in  a  typical 
attitude  to  be  described  as   total  or  postural  lateral  curvature  in  the 

'  "Archiv  f.  orth.  Chir.,"  i,  i,  2. 


Fig.  34. — E.XPERI.MENTAL  SCOLIOSIS 

IN  A  Young  Dog  Produced  by 
Bandaging  in  a  One-sided 
Position.— (  Wullsteiu.) 


44  MECHANISM   OF   SCOLIOSIS. 

chapter  on  Description  and  Symptoms.  This  attitude  may  persist  as 
such  or  change  to  the  second  form  to  be  described  next. 

The  second  type  of  lateral  curvature  implies  a  change  in  the  shape 
of  the  bones.  It  cannot  be  reproduced  experimentally  in  the  model, 
cadaver,  or  child,  and  is  not  within  the  physiological  limits  of  the  spine. 
It  must,  therefore,  be  classed  as  structural  or  organic  lateral  curvature. 
The  characteristic  feature  is  a  local  backward  prominence  of  the  ribs 
or  lumbar  transverse  processes  opposite  the  lateral  curv^e,  and  this 
backward  prominence  or  bony  rotation  is  always  backward  on  the 
side  of  the  convexity  of  the  lateral  curve,  i.  e.,  left  in  left  curves. 

Bony  Rotation. — The  reason  for  this  seems  to  be  fairly  plain. 
A  permanent  curve  is  forming,  we  will  say,  convex  to  the  left;  the  verte- 
bral bodies  in  their  growth  will  follow  the  line  of  least  resistance,  and 
if  they  are  plastic,  they  will  expand  where  the  pressure  is  least  and 
become  compressed  where  it  is  greatest.  They  will  turn  away  from 
the  line  of  weight,  which  is  obviously  nearer  the  concave  than  the  con- 
vex border,  and  their  avenue  of  escape  is  toward  the  convex  border 
or  away  from  the  middle  line  of  the  body.  If  they  were  to  turn  toward 
the  middle  line  instead  of  away  from  it  they  would  encounter  the  greater 
resistance  and  have  to  raise  the  whole  weight  of  the  parts  above  them. 
In  so  far  as  they  are  plastic  they  will  be  compressed  where  the  weight 
is  greatest  or  on  the  concave  side.  The  deformity  of  the  vertebrje 
is  therefore  due  to  their  plasticity  yielding  to  conditions  of  unequal 
strain,  and  turning  where  they  must  to  escape. 

Double  Curves. — The  explanation  of  a  double  curve  is  more  difficult. 
It  has  been  observed  that  frequently  a  double  organic  curve  grows 
out  of  a  single  functional  one,  the  reason  for  which  will  be  explained 
in  the  chapter  on  Description  and  Symptoms.  It  cannot  be  said  that 
every  case  of  organic  double  curve  has  first  been  a  single  postural  one, 
for  congenital,  early  rachitic,  and  other  cases  make  that  unlikely, 
but  the  mechanism  is  present  for  forming  double  curves  from  single 
ones  under  the  influence  of  existing  conditions.  The  occurrence  of 
bony  change  in  some  cases  and  the  persistence  of  functional  curves 
in  others  can  only  be  explained  by  assuming  a  plasticity  of  the  bones 
in  certain  individuals  which  does  not  exist  in  the  bones  of  others. 

But  lateral  curvature  is  not  wholly  an  affair  of  the  upright  position — 
its  occurrence  in  quadrupeds  shows  that ;  again  it  is  seen  as  a  congenital 
condition,  and  in  empyema  and  paralysis  it  would  probably  occur  if 
recumbency  were  substituted  for  the  upright  position.  Yet  in  quad- 
rupeds the  phenomena  are  the  same  as  in  cases  which  are  the  result 
of  superincumbent  weight,  the  spines  of  the  animals  showing  a  rotation 


DOUBLE   CURVES.  45 

of  vertebral  bodies  backward  on  the  convex  side  of  the  lateral  curve, 
in  spite  of  the  fact  that  superincumbent  weight  is  absent  as  a  deforming 
factor. 

The  chain  of  events  in  the  cases  where  a  single  curve  changes  to 
a  double  one  is  then,  first,  a  disturbance  of  the  symmetry  of  the  body 
and  the  appearance  of  a  functional  curve;  second,  the  persistence  of 
this  curve  from  the  same  causes  that  started  it,  the  phenomena  being 
still  within  the  normal  mechanism  of  the  spine;  third,  the  yielding  of 
plastic  vertebrae  in  the  line  of  least  resistance  and  the  appearance  of 
rotation  on  the  convex  side  of  the  lateral  curve;  fourth,  the  formation 
of  double  curves  from  single  ones  by  the  normal  mechanism  of  the  spine 
originating  in  the  sense  of  balance  and  adjustment.  It  seems  that  in 
many  cases,  perhaps  the  majority,  these  steps  cannot  be  traced,  but 
coincide  in  time. 


IX 


Chapter  IV. 
DESCRIPTION  AND  SYMPTOMS. 

SYNONYMS. 

English:  Scoliosis,  lateral  curvature  of  the  spine,  rotary  lateral 
curvature  of  the  spine. 

German:  Skoliose,  seitliche  Ruckgratsverkriimmung,  Kypho-sko- 
liose. 

French:   Scoliose,  deviation  laterale  de  la  taille. 

Italian:    Scoliose. 

Scoliosis,  or  lateral  curvature  of  the  spine,  is  the  name  applied  to  a 
condition  in  which  any  series  of  vertebral  spinous  processes  shows  a 
constant  deviation  from  the  n||dian  line  of  the  body,  a  deviation  always 
accompanied  by,  an  element'^f  twisting.  In  certain  rare  cases  the 
twisting  may  be  the  predominant  appearance.  Deviation  of  a  single 
vertebra  from  the  sagittal  plane  does  not  constitute  scoliosis. 

Although  scoliosis  is  generally  studied  and  classified  as  a  deformity 
of  the  spine,  the  laws  of  equilibrium  of  the  body  are  such  that  any 
deviation  of  the  vertebral  column  must  disturb  the  whole  balance  of 
the  body,  and  scoliosis  is  therefore  accompanied  by  compensating 
displacement  of  the  pelvis  and  legs.  In  this  wider  sense  scoliosis  is 
to  be  regarded  as  a  deformity  of  the  whole  body,  especially  manifest 
in  the  spine. 

Lateral  curvature  of  the  spine  has  for  its  chief  clinical  characteristic 
a  distortion  of  the  symmetry  of  the  body  for  which  the  patient  or  her 
parents  seek  advice.  It  is  rarely  recognized  by  the  laity  as  a  spinal 
distortion,  but  the  patient  is  brought  for  surgical  advice  because  of  "a 
high  shoulder,"  "a  prominent  hip,"  or  "a  projecting  shoulder-blade." 
Very  often  the  dressmaker  is  the  first  to  recognize  it  because  she  finds 
that  she  must  make  the  skirt  longer  on  one  side  than  on  the  other,  or 
because  the  distance  from  the  armhole  of  the  waist  to  the  waistband 
is  longer  on  one  side  than  on  the  other. 

The  condition  is  throughout  a  distortion,  and  symptoms  other  than 
the  deformity  are  rather  unusual  in  average  cases.  Occasionally  the 
patient  complains  of  feeling  "  one-sided, "  but  this  is  rare.  Pain  is  gener^ 
ally  not  complained  of,  but  in  neurasthenic  young  women,  especially 

46 


TERMINOLOGY.  h 

with  functional  curves,  backache  may  be  felt  more  or  less  on  standing. 
Pain  in  the  severer  cases  is  caused  by  the  descent  of  the  ribs  to  the  level 
of  the  crest  of  the  ilium  against  which  the  lower  ribs  may  rub,  and 
severe  local  pain  may  be  felt.  In  other  severe'  cases  nerve-root  pres- 
sure may  result  from  the  distortion  and  be  referred  to  the  peripheral 
ends  of  the  spinal  nerves. 

The  shortening  of  the  trunk  and  the  diminished  capacity  and  im- 
mobility of  the  thorax  may  lead  to  impairment  of  the  function  of  thoracic 
and  abdominal  organs,  and  in  severe  cases  this  must  result  to  some 
extent.  Shortness  of  breath  is  common  in  such  cases  on  account 
of  diminished  respiratory  capacity  and  displacement  of  the  heart. 
Phthisis  frequently  occurs  in  severe  cases  during  adult  life.  Disturb- 
ances of  digestion  are  also  frequent  from  displacement  of  the  stomach 
and  liver.  Impairment  of  vigor  is  the  rule  in  adults  with  scoliosis  of 
the  severer  grades,  and  impairment  of  the  general  health  generally  results 
in  severe  cases  in  adult  life,  although  children  with  severe  curves  as 
a  rule  suffer  but  little  deterioration  of  the  general  condition. 

It  is  not  uncommon  for  patients  to  sp  through  life  with  curves  of 
moderate  degree  which  have  given  rise  to  little  or  no  trouble;  but  after 
the  age  of  fifty  or  sixty,  when  atrophy  of  the  intervertebral  discs  has 
become  marked,  such  curves  may  increase  and  give  rise  to  a  sense  of 
asymmetry  or  to  pain  in  the  back  or  at  nerve  terminations.  It  can 
generally  be  predicted  that  a  curve  of  moderate  severity  may  be  more 
troublesome  in  later  adult  life. 

TERMINOLOGY. 

The  terms  used  in  describing  lateral  curvature  must  be  defined. 
Curves  are  named  right  or  left  according  to  their  convexities,  curves 
convex  to  the  right  being  called  right  curves  and  vice  versa.  In  addi- 
tion to  the  terms  right  or  left  the  curves  are  named  also  according  to 
the  anatomical  region  involved  in  the  curves.  If  a  deviation  involves 
the  whole  spine,  it  is  called  a  total  curve;  all  other  curves  are  called 
cervical,  dorsal,  or  lumbar,  according  to  the  region  involved,  with  the 
qualifying  adjective  right  or  left  preceding  the  anatomical  name.  If 
a  curve  involves  more  than  one  region,  it  is  classed  as  cervicodorsal 
or  dorsoiumbar.  If  two  curves  exist,  the  upper  curve  is  spoken  of 
first  a'ld  the  lower  follows,  e.  g.,  right  cervicodorsal,  left  dorsoiumbar; 
or  right  dorsal,  left  lumbar. 

•  It  is  important  that  the  anatomical  region  affected  by  the  curve  be 
chisignated  accurately  and  not  loosely.  For  this  purpose  the  seventJi. 
cervical  and  last  lumbar  vertebral  spines  are  connected  by  a  string  repre- 


48  DESCRIPTION   AND   SYMPTOMS. 

senting  the  long  axis  of  the  spine.  Parts  of  the  spine  lying  to  the  right 
of  this  line  are  to  be  classified  as  right  curves,  parts  to  the  left  as  left 
curves.  Such  curves  must  be  assumed  to  begin  and  end  vi'here  they 
pass  under  this  string.!  For  example,  if  the  spine  from  the  seventh 
cervical  to  the  twelfth  dorsal  is  to  the  right  of  the  line  and  below  it  is 
to  the  left,  it  is  a  right-dorsal,  left-lumbar  curve.  If  the  spine  from  the 
fourth  dorsal  to  the  third  lumbar  is  to  the  right  of  the  line,  it  is  a  right 
dorsolumbar  cun-e. 

This,  therefore,  provides  for  a  simple  rule  for  the  naming  of  every 
curve,  insisting  on  the  fact  that  the  location  of  the  upper  end  of  the  col- 
umn has  nothing  to  do  with  the  naming  of  the  curve.  The  upper  end 
of  the  spine  may  be  in  the  median  plane  or  at  either  side  of  it  without 
affecting  in  any  way  the  recognition  and  description  of  the  spinal  devia- 
tion. 

The  classification  of  curves  into  primary  and  secondar}',  or  com- 
pensatory, is  not  of  great  importance.  Often  it  is  obvious  that  one 
curve  is  predominant  and  evidently  the  one  to  be  attacked  in  treatment. 
In  other  cases  this  cannot  be  done,  as  the  cur\-es  are  of  equal  degree 
and  importance  so  far  as  can  be  seen.  It  is,  however,  of  importance 
to  recognize  the  predominant  cun-e  where  possible.  For  example, 
in  a  marked  and  predominant  right  dorsal  curve  it  matters  but  little, 
practically,  whether  a  slight  lumbar  cun-e  exists  or  not;  for  purposes 
of  treatment  the  case  is  a  dorsal  curve.  If  a  marked  lumbar  curve 
exists  with  a  dorsal  curve,  however,  the  situation  is  wholly  different. 
In  general  rational  treatment  must  eliminate  unimportant  factors  and 
deal  with  the  salient  ones. 

The  former  division  of  lateral  curvature  into  stages  has  no  rational 
basis.  It  is  a  progressive  affection  passing  over  only  one  sharp  line, 
the  transition  from  postural  or  functional  curves  to  structural  or  organic 
ones.  This  classification  of  functional  and  structural  will,  therefore, 
be  adopted  here  with  slight  emphasis  on  a  certain  puzzling  type  of 
cases  evidently  in  the  transitional  stage  from  the  functional  to  the 
structural  type. 


FUNCTIONAL  SCOLIOSIS  (TOTAL  SCOLIOSIS;  POSTURAL 

SCOLIOSIS). 

The  term  "total  scoliosis"  is  applied  to  cases  where  the  spine  iorms 

01- e  gradual  curve  to  one  side  without  marked  rotation  or  compel  sa- 

tory  curves.     In  90  per  cent,  of  the  cases  the  curve  is  to  the  left.     Acconl- 

ing  to  the  figures  of  Scholder  and  at  the  Children's  Hospital  clinic, 


FUNCTIONAL   SCOLIOSIS. 


49 


right  total  scoliosis  is  very  rarely  seen,  while  the  left  curve  is  very  common. 
The  greatest  point  of  deviation,  i.  e.,  the  apex  of  the  curve,  is  generally 
found  at  the  ninth  or  tenth  dorsal  vertebra,  but  it  may  be  found  in  any 
part  of  the  lower  half  of  the  dorsal  or  upper  half  of  the  lumbar  region. 
In  frequency  of  occurrence  total  scoliosis  stands  in  the  fourth  place 
in  the  records  of  the  institute  of  Liining  and  Schulthess,  where  patients 

came  for  treatment,  forming  but 
15.39  P^^  cent,  of  the  entire 
number  of  lateral  curvatures. 
As  to  sex,  the  percentage  shown 
in  these  cases  is  24  for  males 
and  17  for  females.  In  boys 
the  number  of  total  scolioses 
increases  steadily  with  age,  but 
in  girls  a  decrease  is  noted 
after  the  twelfth  year,  coincid- 
ing with  an  increase  in  the 
number   of  left  lumbar  curves. 


Fig.  35.— Left  Total  Curve. 


Fk;.  36. — Left  Total  Curve  Bent  For- 
ward, Showing  Prominence  of  Back 
ON  THE  Right  (Same  Patient  as  Fig. 

35)- 


Total  scoliosis  is  found  between  the  ages  of  five  and  eighteen  years, 
as  a  rule. 

The  deviation  at  the  greatest  curve  is  not  often  over  an  inch  and  a 
half  from  the  median  line  of  the  body.  There  is  no  obvious  compen- 
satory curve,  and  the  untrained  eye  is  likely  to  find  slight  cases  normal. 
There  is,  however,  a  perceptible  displacement  of  the  trunk  to  the  left, 
especially  as  seen  from  the  front,  and  the  plumb-line  will  detect  a  decided 
4 


50  DESCRIPTION'   AND    SYMPTOMS. 

deviation  of  the  marked  spines  from  the  median  plane.  The  character- 
istics of  the  type  in  a  left  total  scoliosis  are  as  follows:  (i)  A  general 
curve  convex  to  the  left;  (2)  the  left  shoulder  is  elevated;  (3)  the  right 
side  0}  the  shoulder-girdle  is  carried  back  and  the  left  side  forward; 
(4)  when  the  patient  bends  forward  the  right  side  of  the  back  may  be 


Fig.  37. — Radiogram  of  Total  Curve  in  Patient  Shown  in  Fig.  35. 


slightly  higher  than  the  left.  Any  case  in  which  these  signs  are  not 
all  present  should  be  subjected  to  the  closest  examination  and  will 
probably  be  found  to  be  transitional  in  character.  Even  in  apparently 
typical  cases  an  a--ray  taken  in  the  standing  position  will  sometimes 
show  a  slight  tendency  to  curve  to  the  right  in  the  dorsal  region,  which 


FUNCTIONAL   SCOLIOSIS. 


SI 


may  be  due  to  the  physiological  curve  to  the  right  there  or  to  a  beginning 
structural  change.  Functional  curves  disappear  on  suspension  or 
recumbency,  and  side  flexibility  is  but  little  limited,  bending  to  the 
left  being  perhaps  somewhat  restricted.  In  cases  of  right  cur\es 
the  description  is  reversed. 

The  changed  relation  of  the  shoulders  to  the  pelvis  is  more  evident 
in  children  with  a  lumbar  curve  than  in  cases  with  round  backs. ^ 

The  position  in  a  typical  functional  total  curve  is  merely  the  physio- 
logical one  necessitated  in  every 
normal  spine  made  convex  to 
the  left,  and  can  be  produced 
experimentally  by  putting  a 
book  under  the  right  foot, 
which  raises  the  right  side  of 
the  pelvis  and  necessitates  for 
balance  a  left  convex  curve  of 
the  spine.  A  spine  making  any 
bend  convex  to  the  left  in  the 
erect  position  will  turn  at  its 
upper  end  to  the  right,  as  ex- 
plained in  the  movements  of  the 


Fig.  3S. — Case  of  "  Paradoxical  Dorso- 
LUMBAR  Scoliosis"  Figured  by  Wil- 
EOUCHEWITCH.     (Compare   Figs.   35-37.) 


Fig.  39 — Same  Case  as  in  Fig.  38  Bent 
Forward  Showing  Prominence  of 
Ribs  on  Right  Side  with  Left 
Curve. — {Wilboucheivitch.) 


spine.  The  thorax  and  shoulders  will  be  twisted  backward  on 
the  right,  and  when  the  patient  bends  forward,  this  twisted  posi- 
tion of  the  shoulders  may  be  carried  over  into  the  position  of 
forward  bending  if  the  case  has  been  of  long  standing,  and  the 
right  side  of  the  back  will  be  higher  in  this  position.  This  "reverse 
rotation,"  "concave  torsion,"  "retrotorsion,"  as  it  has  been  called, 
has  been  much  discussed-  and  is  an    accompaniment  of   total  scoli- 

^  Srhulthess:    "Zeitsch.  f.  orth.  Chir.,"  vi,  399-566,  1902. 
^  Schulthess:   "Zeitsch.  f.  orth.  Chir.,"  x,  page  489. 


52 


DESCRIPTION   AND   SYMPTOMS. 


osis,  but  it  is  a  physiological  matter  easily  understood  by  studying 
the  mechanics  of  the  normal  spine.  It  has  been  claimed  that  total 
scoliosis  is  really  a  triple-compound  curve/  and  that  the  torsion  to  the 
concave  side  is  really  due  to  a  slight  right  dorsal  curve;  x-rays  of  such 
cases  taken  in  the  standing  position  show,  however,  in  many  cases,  a 
gradual  curve  to  the  left  without  compensating  curves  (Fig.  37);    in 


Fig.  40. — Boy  with  Left  Total  Scoliosis  Photographed  from  Overhead,  Showing 

THE  Carrying  Back  of  the  Shoulder-girdle  on  the  Right. 

The  front  edge  of  the  board  on  the  floor  marks  the  lateral  plane  of  the  pelvis. 

other  cases  apparently  total  curves  in  .T-rays  taken  in  this  way  seem 
to  be  transitional  cases. 


TRANSITIONAL  CURVES. 
In  many  cases  which  on  first  inspection  appear  to  be  postural  more 
careful  examination  will  show  that  the  curve  is  obviously  changing  from 
the  postural  to  the  structural  type,  i.  e.,  is  beginning  to  show  changes 
of  structure.     The  mechanism  of  this  is  as  follows: 

If  total  scoliosis  tends  to  increase,  it  must  do  so  by  an  increase  of  the  existing 
side  bend  and  of  the  existing  twist,  since  both  are  correlated,  not  necessarily  of  both 
in  exact  proportion,  but  to  some  extent  both  factors  must  share  in  it.     The  shoulder- 

*  Reiner  and  Werndorff :  "Verhandl.  Deut.  Gesel.  f.  orth.  Chir., "  1906,  page  232. 


TRANSITIONAL   CURVES. 


53 


girdle  will,  therefore,  be  more  twisted  as  the  lateral  curve  increases.  One,  however, 
does  not  see  the  condition  clinically  of  e.xtreme  left  total  curve  and  extreme  right 
backward  rotation  of  the  shoulder-girdle  except,  possibly,  in  cicatricial,  hysterical,  or 
paralytic  cases.  An  adjustment  apparently  takes  place  when  the  tendency  of  the 
total  curve  to  increase  passes  beyond  a  certain  point.  For  the  explanation  of  this 
one  naturally  looks  to  the  instinctive  tendency  to  equilibrium  and  balance  spoken  of 
as  an  intrinsic  property  of  the  upright  living  spine.  There  must  be  going  on  at  all 
times  this  effort  to  square  the  shoulder-girdle  with  the  pelvis  and  to  keep  the  head 
and  upper  spine  as  nearly  as  possible  in  the  median  line  of  the  body.     This  ad- 


.^, 


Fig.  41. — The  Upper  End  of  the  Spine 
OF  THE  Cadaver  is  Held  by  the 
Hand  over  the  Middle  of  the 
Pelvis,  while  the  Right  Side  of 
THE  Pelvis  is  Raised,  and  a  Posi- 
tion Like  that  of  the  Living 
Model  is  Produced  with  a  Lat- 
eral CiiRVE  Convex  to  the 
Left.     (Cf.  Fig.  31.) 


Fig.  42. — E.xpkrimental  Double 
Curve  (Right  Dorsal,  Left  Lum- 
bar) Prodl'ced  in  the  Cadaver 
BY  Elevating  the  Right  Side  of 
the  Pelvis  and  Twisting  the 
Upper  End  of  the  Spine,  Face  to 
THE  Left. 


justment  will  naturally  occur  where  the  spine  offers  the  least  resistance  to  it,  and  as 
individual  vertebral  columns  vary,  the  compensatory  adjustment  will  take  various 
forms. 

Assume  that  a  child  stands  and  sits  with  a  left  total  curve.  He  will,  after  a 
certain  point  in  the  deformity  is  reached,  be  continually  striving  to  twist  the  upper 
part  of  his  spine  and  his  shoulder-girdle  forward  on  the  right  and  to  bend  the  upper 
part  of  his  spine  convex  to  the  right  to  restore  his  balance.  We  have  seen  that 
the  dorsal  spine  twists  more  easily  than  it  bends  to  the  side.  He  is,  therefore,  more 
likely  to  twist  his  dorsal  spine  than  to  bend  it  to  the  side.     He  will,  for  this  reason, 


54  DESCRIPTION   AND    SYMPTOilS. 

twist  the  upper  dorsal  spine  to  the  left,  which  twist,  as  we  have  seen,  necessarily 
carries  with  it  a  dorsal  lateral  curve  convex  to  the  right. 

The  tendency  to  correct  the  twist  of  the  shoulder  and  upper  end  of  the  spine 
is  sufficient  to  explain  the  transition  of  a  left  total  curve  to  a  right  dorsal,  left  lumbar 
curve.  Such  a  double  curve  can  be  reproduced  experimentally  in  the  cadaver, 
the  model,  and  the  child  by  inducing  a  left  total  curve  and  adding  a  twist,  active 


Fig.  43.— Experimental  Double  Curve  (Right  Dorsal,  Left  Lumbar)  Produced  in 
THE  Model  by  Elevating  the  Right  Side  of  the  Pelvis  and  Having  the  Model 

Actively  Twist  the  Upper  Spine,  Face  to  the  Left. 


or  passive,  of  the  shoulder-girdle  forward  on  the  right.     A  right  dorsal,  left  lumbar 
lateral  curve  then  exists. 

Support  is  given  to  this  idea  by  the  fact  that  in  structural  right  dorsal,  left  lumbar 
curves  with  bony  rotation,  one  is  likely  to  find  in  looking  down  upon  the  standing 
patient  that  the  left  side  of  the  shoulder-girdle  is  seen  to  be  carried  backward  in  its 
relation  to  the  pelvis  and  the  right  side  forward.  This,  of  course,  is  the  reversed 
position  to  that  seen  in  the  left  total  curve.     The  same  relation  of  the  shoulder- 


TRANSITIONAL   CURVES.  55 

girdle  is  to  be  noticed  in  single  curves  to  the  left  which  are  accompanied  by  bony 
rotation,  the  position  again  being  the  reverse  of  that  seen  in  left  total  scoliosis. 

The  disappearance  of  concave-sided  torsion  which  has  once  existed  in  any 
part  of  the  spine  may  indicate  that  the  compensatory  change  has  already  begun 
and  that  the  so-called  total  scoliosis  has  begun  on  its  transition  to  a  compound  curve. 

We  should,  therefore,  regard  with  suspicion  any  case  of  apparent  total  scoliosis 
that  shows  any  departure  from  the  clinical  type  described  (see  page  50).  Such 
cases  must  be  regarded  as  probably  having  entered  on  the  stage  of  transition. 

That  left  total  curves  most  frequently  change  to  right  dorsal,  left  lumbar  com- 
pound curves  than  to  any  other  form  is  shown  by  the  figures  of  Hess  and  by  a 
statement  of  Schulthess.^  But  we  cannot  expect  the  same  final  curves  always 
to  result  from  the  same  initial  curve.  Various  forms  of  curves  may  occur  from 
the  same  simple  curve.  For  example,  the  dorsal  region  may  not  react  as  de- 
scribed, and  the  dorsal  and  lumbar  region  may  yield,  as  a  whole,  to  the  left,  later 
showing  bony  rotation  on  the  left  side.  The  spine  has  yielded  backward  and  to  the 
left  as  a  whole,  and  other  types  of  compound  curves  may  obviously  result  from  the 
same  initial  curve. 

In  such  transitional  cases  the  upper  part  of  the  spine  is  less  curved 
than  the  lower,  and  one  or  more  of  the  characteristic  signs  of  postural 
curves  are  most  often  wanting.  For  example,  the  right  shoulder  may 
be  elevated  in  a  left  curve,  or  the  left  side  of  the  back  may  be  prominent 
upward  in  forward  bending,  or  the  left  shoulder  may  be  carried  forward. 
Such  cases  must,  of  course,  be  recognized  as  early  structural  cases,  but 
are  so  nearly  postural  that  they  may  be  wrongly  classed  unless  identi- 
fied. 

It  is  not  exceptional  to  notice  that  in  a  curve  that  has  been  clearly 
a  typical  postural  one,  a  few  months  later  the  dorsal  spine  is  straight- 
ening and  even  becoming  slightly  curved  to  the  right,  while  the  twist 
of  the  shoulder-girdle  has  disappeared  or  become  reversed. 

In  his  investigations  concerning  the  persistence  of  total  scoliosis 
Hess  records  the  observations  of  86  cases  between  the  ages  of  five  and 
twenty-one  years  during  periods  varying  from  two  weeks  to  eight  years 
and  a  half.  Of  these  86  cases,  60  persisted  as  total  scolioses,  and  the 
remaining  26  underwent  various  changes,  as  shown  by  the  list  given 
below. 

(a)  Left  convex  total  scoliosis  in — 

7  cases    changed    to    right    dorsal,    left    dorsolumbar    scoliosis. 

4  cases  changed  to  left  lumbar  curves,  with  two  right  dorsal. 

3  cases  changed  to  left  dorsal  curves. 

2  cases   changed   to   left   dorsal,   right   dorsolumbar    curves. 

2  cases  changed  to  right  dorsal  curves. 

I  case  changed  to  right  dorsolumbar,   left  dorsal. 

I  case  changed  to  slight  left  cervicodorsal  curve. 

I  case    showed    slight    compensating    curves. 

21  cases. 

1  T.iinr  iT  nnrl    9IrViiiltVif><;<;"     "Orfh     PViir     "    Tnnr     n_    ->  \R. 


56  DESCRIPTION   AND    SYMPTOMS. 

(b)  Right  convex  total  scoliosis  in — 

I  case  became  right  dorsal,  left  dorsolumbar. 

I  case  became  left  dorsal,  right  dorsolumbar. 

I  case  became  left  dorsal. 

I  case  became  right  dorsal. 

I  case  became  left  dorsal,  right  lumbar. 

5  cases. 

STRUCTURAL    SCOLIOSIS  (ORGANIC  OR  HABITUAL 
SCOLIOSIS). 

This  term  is  applied  to  those  cases  in  which  there  is  reason  to  believe 
that  a  structural  change  has  occurred  in  the  vertebrae.  What  this 
structural  change  is,  is  discussed  in  the  chapter  on  Pathology,  but  the 
phenomena  are  no  longer  to  be  explained  in  physiological  terms,  for  the 
spine  has  assumed  a  position  which  implies  organic  change. 

Structural  curves  are  simple  or  compound-^simplewhen  the  deviation 
is  accompanied  by  no  compensating  curves,  e^.  §.,  left  lumbar  scoliosis. 
The  scoliosis  is  compound  when  more  than  one  curve  is  present,  e.  g., 
right  dorsal,  left  lumbar  scoliosis.  The  simple  curves  are  sometimes 
spoken  of  as  C  curves  and  the  double  as  S  curves.  Triple  curves  at 
times  exist.  When  compound  curves  are  present,  they  alternate  to  the 
right  and  left,  two  left  curves  not  separated  by  a  right  curve  never 
being  seen. 

No  attempt  has  been  made  to  discriminate  between  the  words 
"torsion"  and  "rotation,"  and  they  have  been  used  interchangeably 
in  the  text.  The  German  writers  distinguish  between  the  two  terms 
in  a  highly  technical  way,  a  distinction  which  it  does  not  seem  desirable 
to  transfer  to  English.  By  rotation  they  designate  the  turning  of  the 
vertebral  column  as  a  whole  at  the  distorted  region;  by  torsion,  the 
distortion  of  the  individual  vertebra. 

LUMBAR  SCOLIOSIS. 
Lumbar  scoliosis  exists  as  a  simple  curve,  but  more  often  is  only  one 
component  of  a  compound  curve,  the  dorsal  curve  being,  of  course, 
in  the  opposite  direction.  In  the  Schulthess  figures  the  simple  lumbar 
curve  formed  11.7  per  cent,  of  all  cases  treated,  and  right  and  left  curves 
were  of  practically  the  same  frequency.  It  occurs  later  than  the  total 
scoliosis,  as  shown  by  the  ages  of  the  patients  observed.  It  occurs  more 
frequently  in  females  than  in  males  (Scholder:  13.8  per  cent,  boys, 
27.7  per  cent,  girls.  Schulthess:  6.3  per  cent,  males,  12.7  per  cent, 
females).     The  greatest  deviation  from  the  straight  line  is  most  often 


STRUCTURAL  SCOLIOSIS. 


57 


found  at  about  the  second  lumbar  vertebra,  and  as  the  lumbar  region  is 
short,  the  curve  must  be  in  general  a  sharp  one. 

The  trunk  is  displaced  to  the  side  of  the  convexity  of  the  curve  and 
the  line  of  the  waist  flattened  on  that  side,  while  the  waist  on  the  con- 
cave side  is  sunken  in,  and  folds  may  form  in  the  skin  of  the  flank  on 
the  concave  side.  This  is  ex- 
pressed by  an  apparent  promi- 
nence and  greater  size  of  the 
hip  on  the  concave  side,  and  it 
is  popularly  said  that  one  hip 
has  "grown  out"  or  one  hip  is 
"  higher  "  than  the  other.  This 
inequality  of  the  hips  and  waist- 
line is  the  most  striking  feature 
of  lumbar  curves,  and  unless 
corrected  forms  an  unsightly 
deformity  in  women  with 
prominent  hips  and  makes  it 
necessary  to  make  the  skirt^ 
longer  on  one  side  than  on  the 
other.  The  height  of  the  shoul- 
ders is  not  noticeably  affected 
by  lumbar  curves. 

As  the  patient  stands,  a  full-' 
ness  of  the  back  is  noticed  in 
marked  cases  on  the  convex  side 
of  the  curve  caused  by  the  ro- 
tation of  the  vertebrae,  which 
carry  the  heavy  transverse  pro- 
cesses around  and  make  promi- 
nent the  overlying  structures. 
In  the  position  of  extreme  for- 
ward bending  the  side  of  the 
back  which  is  on  the  convexity 
of  the  lateral  curve  is  prominent 

upward,  but  lumbar  rotation  is  always  less  prominent  than  dorsal,  and 
to  the  untrained  eye  even  in  the  severer  cases  seems  slight  (Fig.  51). 
In  side  bending  mobility  is  greater  toward  the  side  which  makes  the 
curve  worse  than  to  the  side  which  improves  it  (Fig.  55). 


Fig.  44. — Left   Lumbar   Scoliosis  not  Re- 
turning TO  the  Median  Line. 
The   lines  indicate  the  median  plane  and  the 
flexibility  to  each  side. 


58 


DESCRIPTION   AND    SYMPTOMS. 


DORSAL  SCOLIOSIS. 
A  single  dorsal  curve  is  more  frequent  than  the  single  lumbar  type, 
but  is  much  less  frequent  than  dorsal  curves  in  combination  with  other 
forms;  that  is  to  say,  dorsal  curves  are  more  often  than  not  accom- 
panied by  reverse  or  compensating  curves  above  or  below.  In  the 
Schulthess  figures  there  were  19  per  cent,  of  single  dorsal  curves  and 
30  per   cent,   where  dorsal   curves   existed  with  others.     The  curves 

are  as  frequently  to  the  right  as 
to  the  left  when  they  exist  alone. 
The  point  of  greatest  curve  is 
from  the  sixth  to  the  eighth  dor- 
sal vertebra  in  the  majority  of 
cases. 

In  a  marked  right  dorsal 
curve,  as  seen  from  behind,  the 
thorax  is  displaced  to  the  right, 
and  the  right  arm  hangs  further 
from  the  side  than  the  left;  the 
right  shoulder  is  raised  and  the 
waist-line  on  the  right  is  less  con- 
cave and  much  flattened  in  the 
severer  cases,  the  ribs  coming 
close  to  the  crest  of  the  ilium 
and  obliterating  the  natural 
waist  indentation.  The  rota- 
tion is  made  evident  by  a  promi- 
nence, in  the  back,  of  the  right 
side  of  the  thorax,  which  may 
be  seen  as  the  patient  stands 
erect  (Fig.  49).  Unlike  the 
rotation  in  lumbar  cases,  the 
rotation  element  in  dorsal  cases 
is  a  very  marked  feature  of  the  deformity,  and  a  sharp  prominence 
extends  down  the  right  side  of  the  thorax,  composed  of  the  angles  of 
the  ribs,  which  pushes  the  scapula  backward  and  to  the  right.  The 
left  side  of  the  thorax  as  seen  from  behind  is  flat  or  concave,  the  left 
scapula  sunken  and  rotated  with  the  glenoid  cavity  downward  and 
the  inferior  angle  inward.  A  fold  in  the  skin  frequently  runs  inward 
and  upward  from  the  waist-line.  "When  the  patient  bends  forward 
until  the  trunk  is  horizontal,  the  rotated  ribs  are  very  prominent  upward 


Fig.  45.— Advanced  Right  Dorsal  Scoli 
osis  in  an  Adult. 


DORSOLIIMBAR   SCOLIOSIS. 


59 


on  the  right,  and  a  long  arch  of  rib  angles  is  seen  which  is  much  more 
marked  than  in  the  standing  position.  On  the  left  side  the  ribs  are 
sunken  and  fall  away,  making  a  fiat  and  even  depressed  surface  to 
contrast  with  the  striking  prominence  of  the  right  side. 

As  seen  from  the  front,  the  deformity  is  even  more  evident,  the 
thorax  is  displaced  to  the  right,  the  right  shoulder  is  higher  than  the 
left,  and  the  left  side  of  the  thorax  more  prominent  in  front  than  the 
right.  In  severe  cases  the  lower  end  of  the  sternum  is  generally  displaced 
toward  the  convexity  of  the  curve — in  this  case  to  the  right.  The  contour 
of  the  chest  is  changed,  and  the  longest  thoracic  diameter  is  from  the 
point  rotated  backward  on  the 
right  to  the  point  rotated  for- 
ward on  the  left — in  this  case 
from  the  right  scapula  to  the 
left  nipple.  This  description 
is,  of  course,  to  be  reversed  for 
left  dorsal  curves. 

The  dorsal  physiological 
curve  is  most  often  increased, 
making  the  rounded  and  dis- 
torted back  spoken  of  as  kypho- 
scoliosis (Fig.  46).  It  may, 
however,  be  flattened,  and 
even  slightly  concave  forward 
in  the  dorsal  region.  The 
loss  of  height  and  shortening 
of  the  trunk  are  evident  in  the 
severer  cases.  The  picture  is 
wholly  different  from  that  seen 
in  lumbar  cases,  where,  as  has 
been  said,  the  chief  noticeable 
distortion  is  in  the  hips  and 
waist-line;  in  dorsal  cases  the  distortion  is  most  noticeable  in  the 
thorax  and  shoulders. 

DORSOLUMBAR  SCOLIOSIS. 
Dorsolumbar  scoliosis  is  a  form  seen  as  a  simple  curve  with  con- 
siderable frequency  (20  per  cent.),  being,  therefore,  much  more  common 
than  simple  lumbar,  but  about  as  frequent  as  simple  dorsal  scoliosis. 
It  naturally  partakes  of  the  character  of  the  two  forms  just  described 
and  aft'ects  nine  females  to  one  male.     The  seat  of  greatest  curve  is 


Fig.  46,— K^■PHOscoLIosIS. 


6o 


DESCRIPTION   AND   SYMPTOMS. 


generally  at  the  dorsolumbar  junction.  It  is  four  times  as  frequently 
convex  to  the  left  as  to  the  right.  The  trunk  and  lower  thorax  are 
displaced  toward  the  side  of  the  convexity  of  the  cun-e  and  overhang 
the  pelvis,  and  the  waist-line  on  that  side  is  flattened  or  obliterated, 
while  on  the  concave  side  the  outline  cuts  in  sharply  above  the  pelvis, 
frequently  forming  folds  in  the  skin.  The  attitude  is  more  like  that 
of  an  exaggerated  total  scoliosis  than  like  either  the  dorsal  or  lumbar 
form.      The    severest    cases    are    characterized    by    a    kyphosis    of 

the  spine  (kyphoscoliosis).  It 
is  not  so  prone  to  be  associated 
with  compensatory  curves  as 
are  the  other  forms. 

CERVICODORSAL 
SCOLIOSIS. 

Cervicodorsal  scoliosis  is  a 
comparatively  rare  form  of  the 
deformity,  occurring  in  only 
3.6  per  cent,  of  all  cases.  It 
is  convex  to  the;  left  more 
often  than  to  the  right  in  the 
relation  of  3  to  2,  and  the  great- 
est curve  is  most  frequently 
located  at  the  third  or  fourth 
dorsal  vertebra.  The  head  is 
carried  forward  and  tipped  to 
the  concave  side  of  the  curve. 
The  neck  is  obviously  short- 
ened, and  the  outline  from  the 
base  of  the  skull  to  the  shoul- 
der is  fuller  and  less  crescentic 
in  outline  on  the  convex  side  of 
the  curve  than  on  the  other. 
The  shoulder  on  the  convex  side  of  the  curve  is  raised  and  the  other 
lowered,  and  the  scapula  of  the  raised  side  is  conspicuously  higher. 
The  arm  of  the  convex  side  hangs  further  from  the  side  than  the 
other.  JThe  rotation  appearances  are  marked,  and  the  sharp  angles 
of  the  upper  ribs  are  prominent  in  the  lower  part  of  the  curve,  while 
above  the  rotation  is  less  evident  because  there  are  only  the  transverse 
processes  of  the  cervical  vertebrae  to  make  a  projection.  The  trunk  is 
displaced  to  the  side  of  the  convexity  of  the  lateral  curve. 


Fig.  47. — Left  Dorsolumbar  Scoliosis, 


COMPOUND   STRUCTURAL  CURVES. 


6l 


COMPOUND  STRUCTURAL  CURVES. 

The  pictures  of  compound  curves  cannot,  of  course,  be  as  simple 

or  uniform  as  those  of  the  simple  types.     A  right  dorsal  left  lumbar 

curve,  for  example,  will  present  a  combination  of  the  appearances 

described   in  both   dorsal    and    lumbar  curves,   a  right  cervicodorsal 

left  dorsolumbar  the  sum  of  the 
pictures  of  the  two  factors.  If  the 
dorsal  element  predominates,  the 
appearances  will  be  more  dorsal 
than  lumbar,  as  is  usually  the  case, 
and  every  grade  of  variation  is  to 


Fig.  48.— Cervicodorsal  Curve  due 
TO  Defective  Ribs  and  Malfor- 
mation OF  VERTEBR/E. 


Fig.  49.— Right  Dorsal  Left  Lum- 
bar Scoliosis. 


be  seen,  the  predominant  curve  setting  its  type  on  the  clinical  appear- 
ance. The  right  dorsal  left  lumbar  curve  is  the  one  most  frequently 
seen.  Dorsal  scoliosis  with  compensating  curves  formed  30  per  cent, 
of  all  cases  in  the  Schulthess  tables,  and  of  these  the  dorsal  curve 
was  to  the  right  in  80  per  cent,  of  the  cases.  The  greatest  point 
of  curve  in  these  was  from  the  sixth  to  the  eighth  dorsal  vertebra,  and 


62 


DESCRIPTION   AND   SYMPTOMS. 


the  most  frequent  reverse  curve  associated  was  in  the  lumbar  region. 
It  is  a  type  of  curve  most  frequently  seen  in  older  children,  the  bulk  of 
the  cases  being  from  ten  to  sixteen  years  old,  but  it  may  be  seen  in  very 
young  children.  The  increased  susceptibility  to  compound  curves 
with  increasing  vears  is  shown  bv  Scholder's  statistics  of  school  children: 


years  old 0.4  per  cent. 


13 
14 


.1.1 

.1.2 
.2.4 
.2.1 

■3-'3 
■3-3 


Women   are   more   frequently   affected   than   men,   the   proportion 

being  7  to  i. 

The  appearances  shown  in  the 
ilkistration  (Fig.  49)  will  serve  to 
demonstrate  how  the  appearances 


Fig.  50.— Dorsal  Rotation  Shown  ev 
Prominenck  of  Right  Side  in  Bend- 
ing Forward.     (See  Fig.  49.) 


Fig.  51. — Lumbar  Rotation  Shown  by 
Prominence  of  Left  Side  in  Bend- 
ing Forward.     (See  Fig.  49.) 


of  two  types  of  simple  scoliosis  are  brought  together  in  the  same  patient. 
In  a  right  dorsal  left  lumbar  curve,  the  appearances  of  the  thorax  are 
those  described  for  a  simple  dorsal  curve,  but  the  overhang  of  the 
thorax  is  modified  by  the  displacement  of  the  lower  trunk  in  the 
opposite  direction  incident  to  the  left  lumbar  curve.  The  resultant 
position  may  be,  as  in  the  simple  curves,  either  accompanied  by  an 
increase  or  diminution  of  the  physiological  curves. 

That  scoliosis  may  change  in  type  from  one  clinical  picture  to  another 
in  the  same  patient  in  the  course  of  years  is  well  established.  Not 
only  does  the  total  curve  frequently  change  to  a  compound  type  as 
mentioned,  but  the  structural  curves  change  most  frequently  by  the 


COMPOUND    STRUCTURAL   CURN'ES. 


63 


addition  of  compensatory  curves,  e.  g.,  the  illustration  shows  the  change 
of  a  right  dorsal  to  a  right  dorsal  left  lumbar  curve  (Figs.  52  and  53). 
The  frequency  of  this  is  not  yet  known,  and  can  only  be  determined 
when  a  sufficient  numl)er  of  exact  records  reaching  over  a  series  of 
years  has  been  accumulated. 


Fig.  52. — ScHULTHESs'  Tracing  of  a  Girl       Fig.  53. — Tracing  of  the  Same  Case  Eight 
Six  Years  Old. — (Schulthess.)  Years  l^xvKK.—iSchidthess.) 

The  frequency  of  the  common  types  as  tabulated  in  1137  cases 
by  Schulthess  was  as  follows : 

Total  scoliosis. ; 15-39  P^r  cent. 

Lumbar 11. 7 

Dorsal 19 

Dorsolumbar 20 

Cervicodorsal 3.6 

Compound 30 


Chapter  V. 


EXAMINATION  AND  RECORD  OF  SCOLIOSIS. 

It  is  a  matter  of  practical  importance  that  an  accurate  examination 
and  reliable  record  be  made  of  cases  of  scoliosis,  for  not  only  is  it  essen- 
tial for  accurate  treatment  that  the  curves  be  clearly  formulated  at  the 
outset,  but  progress  under  treatment  is  only  to  be  estimated  by  a  com- 
parison of  such  records. 

The  following  points  are  of  importance: 

Family  History. — The  occurrence  of  scoliosis  in  the  family  and  the  his- 
tory of  any  hereditary  deformity.     The  existence  of  a  tuberculous  history. 

Personal  History. — The  character  of  the  labor.  The  health  of 
the  child  as  a  baby.  Whether  nursed  or  bottle-fed.  The  history  of 
infectious  and  other  sicknesses.  The  age  at  which  dentition  began, 
the  date  of  walking,  and  the  existence  of  bowlegs  or  any  signs  suggest- 
ing rickets.  The  age  at  which  the  curve  was  noted  and  its  progress 
since  observation.  The  child's  mental  make-up,  progress  at  school, 
resistance  to  fatigue,  and  liability  to  slight  illnesses.  The  character 
of  growth,  whether  recent  or  not,  whether  rapid  or  slow.  The  relative 
height  and  weight  of  the  child  are  of  importance  and  should  be  taken 
and  compared  to  the  average  given  in  the  table,  as  in  formulating  the 
prognosis  it  is  important  to  know  if  the  child  is  of  average  development 
and  if  it  may  reasonably  be  expected  to  have  in  prospect  a  considerable 
period  of  growth. 

Average  Heights  and  Weights. — {T.  M.  Rotch.) 


BOYS. 

Age. 

GIRLS. 

Height. 

Weight. 

Weight. 

Height. 

Inches. 

Pounds. 

Pounds. 

Inches. 

19-75 

7-15 

Birth. 

6-93 

19-25 

24-75 

14.30 

5  mos. 

13.86 

23-25 

29-53 

20.98 

I  year. 

19.80 

29.67 

ii-^^ 

30.36 

2  years. 

29.28 

32-94 

37.06 

34.98 

3      " 

33-15 

36.31 

39-31 

37-99 

4      " 

36.36 

38.80 

41-57 

41.00 

5     " 

39-57 

41.29 

43-75 

45-07 

6     " 

43.18 

43.35 

45-74 

4S.97 

7      " 

47.30 

45-52 

47.76 

53.81 

8     " 

51-56 

47-58 

49.69 

59.00 

9      " 

57.00 

49-37 

51.68 

65.16 

10      " 

62.23 

51-34 

53-33 

70.04 

II      " 

68.70 

53.42 

55-11 

76.75 

12      " 

78.16 

55-88 

57-21 

84.67 

13      " 

88.46 

58.16 

59.88 

94-49 

14     " 

98.23 

59-94 

64 


EXAMINATION   FOR   SCOLIOSIS.  65 

The  weights  at  birth,  and  in  the  first,  second,  and  third  years,  were 
without  clothing.  The  ordinary  school  clothes  were  worn  in  the  weigh- 
ing from  five  to  fourteen  years. 


EXAMINATION. 

GENERAL  CONDITION. 
Nutrition  and  development.  Color.  Nervous  condition.  Con- 
dition of  muscles.  Condition  of  heart  and  lungs.  Chest  expansion. 
Comparative  length  of  legs.  Flat-foot.  Whether  or  not  spectacles 
are  worn.  General  attitude  and  carriage.  Manner  of  wearing  cloth- 
ing, whether  objectionable  or  not. 

EXAMINATION  OF  SPINE. 

A  patient  with  suspected  lateral  curvature  should  always  be  ex- 
amined with  the  back  wholly  bare.  The  clothes  should  be  firmly  pinned 
or  fastened  by  a  strap  around  the  hips  at  a  level  low  enough  to  show 
the  top  of  the  cleft  between  the  buttocks  and  to  show  the  outline  of 
the  hips.  In  children  the  patients  should  be  stripped  to  this  level;  in 
adolescent  and  adult  young  women  the  chest  should  be  covered  by 
an  apron  hanging  over  the  front  of  the  thorax,  the  strings  of  which 
are  fastened  around  the  neck. 

The  patient  should  stand,  back  to  the  surgeon,  squarely  on  both  feet 
with  the  arms  hanging  at  the  sides.  It  is  desirable  lo  allow  the  patient 
to  stand  quietly  for  a  minute  or  two  before  beginning  the  examination 
in  order  to  secure  the  fatigued  or  relaxed  position  which  is  the  character- 
istic one.  The  patient  should  not  be  handled  or  touched  during  in- 
spection, as  the  contact  of  the  hand  frequently  stimulates  the  muscles 
and  negatives  for  the  time  being  the  relaxed  position. 

Inspection  of  the  natural  standing  position  forms  the  first 
step  in  the  examination.  The  surgeon  notices  first — (i)  the  body  outline, 
whether  symmetrical  or  not,  comparing  on  both  sides  the  outline  from 
the  axilla  to  the  crest  of  the  ilium,  whether  one  is  flatter  or  more  curved 
than  the  other,  whether  one  arm  hangs  further  from  the  side  than  the 
other.  The  apparent  prominence  of  one  hip  is  noted.  The  trained  eye 
estimates  this  asymmetry  as  a  lateral  displacement  of  the  thorax  or 
trunk  with  regard  to  the  pelvis,  and  it  is  the  safest  guide.  The  appre- 
ciation of  symmetry  is  essential  in  giving  corrective  gymnastics,  and 
the  most  useful  method  to  one  trained  is  to  erect  an  imaginary  perpen- 
dicular from  the  cleft  between  the  buttocks  (anal  fold)  and  estimate 
whether  it  cuts  the  trunk  in  the  middle  or  whether  more  of  the  trunk 


66  EXAMINATION   AND   RECORD    OF   SCOLIOSIS. 

lies  to  the  left  or  right  of  it.  It  is  obvious  that  if  any  part  of  the  spine 
is  laterally  curved,  it  must  carry  v\'ith  it  a  segment  of  the  body  to  the 
right  or  left.  This  displacement  will  be  seen  by  a  change  of  body 
outline,  and  a  change  in  body  outline  on  the  two  sides  is  presumptive 
evidence  of  a  lateral  curve.  The  outline  of  the  body  and  displacement 
of  the  trunk  to  one  side  may  always  be  seen  more  plainh'  from  the 
front  than  the  back,  as  the  outline  is  sharper.  In  children  this  method 
should  follow  the  one  described. 

(2)  The  surgeon  next  notices  the  level  of  the  shoulders,  whether 
one  is  higher  than  the  other,  and  whether  this  is  a  constant  position. 
The  elevation  of  one  shoulder  is  generally  a  sign  of  lateral  curvature, 
but  may  exist  rarely  Avith  no  perceptible  curve. 

(3)  The  position  of  the  scapulae  should  then  be  noted  and  the  two 
sides  compared.  It  is  not  of  primary  importance,  but  it  is  desirable 
to  note  their  relative  distance  from  the  spine,  whether  one  or  both  of 
the  scapula;  are  displaced  forward,  and  whether  any  rotation  of  the  bone 
has  taken  place. 

(4)  The  habitual  position  of  the  head  should  be  noted,  whether 
tipped  to  one  side  or  held  constantly  rotated. 

(5)  The  anteroposterior  physiological  curves  should  be  investigated 
and  any  increase  or  diminution  of  the  dorsal  or  lumbar  curves  noted. 

Estimation  of  the  Spinal  Curve. — Over  the  middle  of  each 
spinous  process  a  mark  is  then  made  on  the  skin  by  a  flesh  pencil  or 
by  ink  while  the  patient  still  stands  as  described.  The  skin  must  not 
be  drawn  to  one  side  or  the  other  in  making  these  marks,  or  distortion 
may  be  caused  by  the  movement  of  the  skin  over  the  bony  points. 
This  line  of  marks  is  accepted  as  representing  the  spinal  curve,  although 
it  does  not  accurately  represent  the  position  of  the  bodies  of  the  verte- 
brae (see  Pathology).  If  a  curve  is  present,  the  line  of  marks  will  be 
evident  as  a  curved  instead  of  a  straight  line,  for  a  normal  spine  shows 
a  line  of  marks  forming  a  straight  line  which  lies  in  the  median  plane 
of  the  body. 

The  median  plane  of  the  body  is  readily  determined  by  holding 
a  plumb-line  behind  the  patient,  the  lower  part  of  which  passes  through 
the  cleft  between  the  buttocks.  In  the  normal  spine  each  mark  will 
lie  under  this  plumb-line.  The  dcA-iation  of  any  number  of  spinous 
processes  from  this  line  represents  a  lateral  cur\-e  which  is  anah'zed 
as  described  in  Terminology  (p.  47). 

This  method  of  erecting  a  perpendicular  from  below  is  preferable 
to  the  method  of  dropping  a  plumb-line  from  the  top  of  the  column 
(the  Beely-Kirckhoff  method),  which   introduces  a  confusing  element 


EXAMINATION   FOR    SCOLIOSIS. 


67 


and  does  away  with  the  consideration  of  the  deviation  as  a  problem 
of  support,  making  it  a  problem  of  the  overhang  of  the  top  of  the  column 
with  regard  to  its  base. 

Cervical  curves  must  be  roughly  estimated  by  the  eye,  for  on  account 
of  the  inaccessibility  of  the  cervical  spinous  processes  and  the  instability 
of  the  head,  they  cannot  be  defin- 
itely measured. 

The  surgeon,  having  thus 
recognized  and  described  any 
bodily  asymmetry,  and  having 
identified  and  described  the 
curve,  is  in  a  position  to  in- 
vestigate the  element  of  rota- 
tion or  twist  which  is  essential 
in  every  case. 

Estimation  of  Rotation 
or  Twist. — The  surgeon,  stand- 
ing close  behind  the  patient, 
looks  down  on  her  shoulder- 
girdle  from  above  to  estimate 
whether  it  is  in  the  same  lateral 
plane  as  the  pelvis  or  whether 
twisted  forward  on  one  side  and 
back  on  the  other.  This  is  of 
use  chiefly  in  postural  cases,  and 
in  structural  cases  is  of  less 
value.  By  sighting  the  scapulas 
and  back  of  the  thorax  on  the 
buttocks  it  is  easily  seen 
whether  any  twist  of  the  thorax 
has  occurred  in  relation  to  the 
pelvis.  Evidence  of  rotation  of 
the  ribs  or  lumbar  transverse 
processes     backward     on     the 

convex  side  of  the  lateral  curve,  which  accompanies  structural  cases, 
will  in  severe  cases  be  evident  in  the  standing  position,  but  it  is  generalh- 
examined  for  and  estimated  in  a  position  of  forward  tlexion  of  the 
trunk  sometimes  spoken  of  as  Adams'  position.  The  patient  bends 
forward  until  the  trunk  is  horizontal  with  the  arms  hanging  down  and 
the  knees  not  flexed.  In  tliis  position  the  patient  remains  while  the 
surgeon  glances  along  the  back  from  beliiiKl  or  in  fn)nl,  with  his  head 


Fig.  54.— Thk  Pli'mk-line  ix  thk  Cleft  ok 
THE  Buttocks  to  Determine  the 
Median  Plane  of  the  Body. 


68  EXAMIXATIOX   AND   RECORD    OF   SCOLIOSIS. 

on  a  level  with  the  spine,  and  looks  to  see  whether  either  side  of  the  trunk 
is  more  prominent  upward  in  the  lumbar,  dorsal,  or  cervical  region. 
Any  such  upward  prominence  represents  rotation  or  twist  and  is  a 
most  important  matter.  If  it  occurs  on  the  concave  side  of  the  lateral 
curve  and  involves  the  curved  region,  it  will  be  slight  and  evenly  dis- 
tributed through  the  spine  and  designates  a  afunctional  or  postural 
cun^e.  That  is,  in  a  left  total  postural  ciu^ve  the  right  side  of  the  back 
will  probably  be  more  prominent  upward  in  the  fon\'ard  bent  position. 
If  it  occurs  as  a  well-defined  local  upward  prominence  occupying 
the  curved  region,  it  designates  a  structural  curve  at  that  location, 
the  curve  being  convex  to  the  side  on  which  the  prominence  occurs 
and  occupying  the  same  anatomical  area.  That  is,  a  right  dorsolumbar 
upward  prominence  designates  a  right  dorsolumbar  structural  curve. 
This  must  be  clearly  understood,  for  often  a  cvirve  which  is  obscure 
or  confusing  in  the  upright  position  is  cleared  up  by  a  recognition  of 
its  rotation  as  seen  in  the  forward  bending  position.  For  example, 
a  patient  standing  erect  shows  a  right  dorsal  axrxt,  and  the  inference 
from  the  general  attitude  is  that  a  left  lumbar  curve  probably  also 
exists.  It  is  in  any  event  slight  and  cannot  be  clearly  defined.  If 
the  patient  bends  fonvard,  lumbar  rotation  will  be  present  or  absent, 
and  on  this  showing  lumbar  lateral  deviation  may  be  excluded  or  ac- 
cepted. A  slight  difference  in  the  levels  of  the  back  at  the  sides  of  the 
lumbar  region  in  the  forward  bent  position  is  sufficient  to  establish 
lumbar  rotation. 

Estimation  of  Spinal  Flexibility.— The  patient  should  now  lie  on 
the  face  and  the  position  of  the  spinous  processes  be  noted.  The 
marks  on  the  skin  will  represent  the  curve  of  the  spine  in  the  erect  posi- 
tion, and  any  straightening  of  the  spine  in  recumbency  will  be  shown  by 
finding  that  the  spinous  processes  form  a  less  curved  line  in  recumbency. 
In  postural  curves  the  spine  will  become  straight  in  recumbency,  struc- 
tural cun-es  will  be  perceptibly  straighter  than  when  the  patient  is  erect. 
The  patient  should  now  be  suspended  by  the  arms,  or  preferably .  by 
a  Sayre  head-sling,  enough  to  take  the  weight  off  of  the  spine,  and  the 
straightening  of  the  spine  noted.  The  modification  of  the  asymmetry 
of  the  trunk  by  suspension  is  most  important  and  should  be  carefully 
studied,  whether  the  asymmetry  is  practically  unchanged,  whether 
the  overhang  of  the  thorax  is  corrected,  and  whether  the  patient  becomes 
wholly  symmetrical.  The  position  of  the  patient  in  suspension  repre- 
sents the  maximum  that  may  be  expected  from  treatment  in  that  indi- 
vidual case  unless  further  flexibility  is  restored  by  treatment  directed 
to  that  end.     The  restoration  of  complete  or  almost  complete  symmetry 


EXAMINATIOX   FOR   SCOLIOSIS.  69 

by  suspension  points  to  an  early  case  and  one  amenable  to  treatment, 
for  one  of  the  early  changes  in  structural  curves  is  a  stiffening  of  the 
curved  region  of  the  spine  which  causes  the  persistence  of  the  curve 
under  suspension.  So  far  as  possible  it  should  be  noted  \yhether  the 
improvement  in  symmetry  is  produced  by  a  straightening  of  the  cur\e 
or  curves  or  whether  the  modification  in  asymmetry  is  produced  by  the 
other  parts  of  the  spine.  For  example,  in  a  dorsal  curve,  is  the  relation 
of  the  curved  region  changed  or  is  the  curved  part  simply  pulled  away 
from  the  pelvis  by  a  stretching  out  of  the  lumbar  region  ? 

The  patient  should  then  bend  forward  to  determine  normal  flexi- 
bility forward.  The  average  child  can  touch  the  floor  with  the  fingers 
while  the  knees  are  straight,  while  in  adult  life  less  flexibility  obtains. 

The  flexibility  of  an  individual  spine  is  a  matter  determined  by 
age,  habit,  and  individual  peculiarity.  To  know  in  a  general  way 
what  the  normal  flexibility  at  a  given  age  should  be  is  important  in 
children,  but  in  adults  it  is  so  much  a  matter  of  individual  habit  that 
it  is  of  less  importance.  One  man  of  fifty,  for  example,  who  has  taken 
exercise  may  be  able  to  touch  the  floor  with  his  hands  in  forward  bend- 
ing, while  another  man  of  the  same  age  of  sedentary  life  cannot  get 
his  finger-tips  within  a  foot  of  the  floor  in  the  same  position,  yet  both 
spines  are  normal.  How  rapid  the  change  in  flexibility  may  be  owing 
to  habit  is  shown  by  the  case  of  a  healthy  boy  of  fifteen  who  could  not 
touch  the  floor  with  his  finger-tips  in  forward  bending.  He  injured 
his  knee  and  was  obliged  to  wear  a  ham  splint.  The  exertion  necessary 
to  dress  himself  with  his  leg  stiff  so  increased  his  forward  flexibilitv 
that  in  ten  days  he  could  place  the  palms  of  his  hands  on  the  floor 
without  exertion  in  forward  bending. 

The  patient  then  stands  with  the  elbows  out  and  the  hands  clasped 
behind  the  neck,  and  bends  to  one  side  and  to  the  other.  The  character- 
istics of  side  bending  have  been  fully  described,  and  modifications  and 
restrictions  of  this  are  to  be  studied.  Patients  with  curves  can,  as  a 
rule,  bend  better  to  the  side  that  makes  the  curve  worse  than  to  the 
side  that  improves  it. 

General  Condition. — The  examination  should  conclude  with  an  ex- 
amination of  the  chest  and  heart. 

The  examination  has  been  dealt  with  thus  at  length  because  rational 
treatment  cannot  be  undertaken  without  a  clear  formulation  of  the 
character  of  the  deformity,  and  experience  shows  that  in  the  loose 
use  of  terms  and  in  slipshod  examinations  some  of  the  failures  to  obtain 
proper  results  from  treatment  have  their  origin. 

X-ray. — The  .v-ray  is  of  use  in  showing  the  existence  of  bonv  defects, 


70 


EXAMINATION   AND   RECORD    OF   SCOLIOSIS. 


numerical  variation,  or  other  anomalies,  and  the  presence  of  deformity 
in  the  bones.  It  is  of  great  value  in  showing  the  character  of  the  curve 
in  doubtful  cases,  and  its  results  do  not  always  agree  with  the  clinical 


Fig.  55.— Patient  with  a  Right  Dorsal  Left  Lumbar  Structural  Curve  Bending  to 
THE  Left  and  Right,  showing  the  Comparative  Rigidity  of  the  Lumbar  Region 
TO  Left  Bending  and  of  the  Dorsal  Region  to  Right  Bending. 


appearances,  certain  cases  judged  to  be  apparently  slight  by  clinical 
examination  showing  in  the  x-ray  marked  bony  deformity.  The  amount 
of  rotation  is  indicated  in  the  :x;-ray  by  the  position  of  the  shadow  of  the 
spinous  processes  in  relation  to  the  shadows  of  the  bodies;  normally  the 


RECORD    OF   SCOLIOSIS.  7 1 

spinous  process  appearing  in  the  middle  of  the  body.  But  the  element 
of  distortion  must  be  remembered.  A  patient  is  likely  to  be  twisted  by 
lying  on  the  back  if  rotation  is  present,  and  any  deviation  of  the  tube 
from  the  middle  line  of  the  body  is  expressed  as  distortion  of  the  verte- 
bras. The  rr-ray  does  not  as  yet  provide  a  method  of  accurate  record 
on  account  of  the  ease  with  which  distortion  is  produced  in  shadows. 
rr-Rays  taken  in  the  standing  position  obviously  represent  the  condition 
to  be  treated  more  correctly  than  do  those  taken  in  recumbency. 


RECORD. 

What  is  required  for  record  is  some  accurate  method  within  the 
reach  of  the  average  practitioner  or  specialist  on  the  subject. 

MEASUREMENTS  OF  THE  LATERAL  CURVE. 

Photography,  although  open  to  many  objections,  is  probably  the 
most  generally  available  means  of  record  at  our  disposal. 

The  advantages  are  that  no  more  than  average  amateur  skill  in 
photography  is  required  to  get  with  practice  a  good  picture,  that  the 
record  can  be  made  in  the  physician's  office,  that  the  results  are  fairly 
accurate  if  taken  wdth  great  care,  and  that  good  photographs  may 
be  translated  into  graphic  curves  by  means  of  a  device  to  be  mentioned. 

The  objections  are  that  practice  is  required  to  obtain  proper  results, 
that  lights  must  be  studied,  that  unsteadiness  of  the  patient  blurs  the 
picture,  that  distortion  is  easily  produced  by  any  carelessness,  and  that 
the  picture  at  best  takes  no  cognizance  of  rotation. 

The  following  rules  must  be  observed : 

1.  The  patient  must  stand  at  ease  with  the  legs  straight  and  the 
arms  hanging  at  the  sides  in  the  relaxed  position,  which  comes  on  at  the 
end  of  about  one  minute. 

2.  The  heels  of  the  patient  must  be  on  a  line  parallel  to  the  lens, 
otherwise  distortion  is  inevitable.  This  relation  must  be  measured 
and  not  left  to  guesswork.  The  simplest  solution  is  to. have  a  stand  for 
the  patient  which  is  provided  with  two  leathers  for  the  heels.  This 
stand  is  always  placed  in  a  definite  location,  the  relation  of  which  to 
the  camera  is  formulated. 

3.  The  patient  must  stand  at  a  fixed  distance  from  the  camera  in 
all  cases  if  pictures  are  to  be  used  as  accurate  records. 

4.  The  light  must  be  oblique  from  behind,  preferably  diffused, 
and  not  the  direct  light  of  the  sky  if  possible,  which  gives  too  violent 
contrasts  between  light  and  shadow.     A  light  from  overhead  throws 


72 


EXAMINATION  AND   RECORD   OF   SCOLIOSIS. 


the  shadow  of  the  shoulders  onto  the  back  and  obscures  the  spinal 
furrow.  A  light  directly  from  behind  gives  a  flat  white  picture  without 
contours.  A  light  directly  from  the  side  throws  the  shaded  part  of  the 
body  into  such  blackness  that  the  body  outline  of  that  side  is  lost.  A 
crossed  light  obliterates  contour  and  gives  a  flat  and  confusing  picture. 

5.  The  shadows  must  be  diminished  by  a  white  reflector  on  the  side 
of  the  patient  away  from  the  light.  This  is  easily  obtained  by  the  use 
of  a  common  clothes-horse,  one  surface  of  which  is  covered  with  sage 
green,  which  serves  as  a  background,  while  the  other  wing  is  covered 
with  white  to  serve  as  a  reflector.  The  patient  faces  the  green  surface 
while  the  white  surface  is  placed  at  the  desired  angle  to  throw  the 
light  onto  the  shaded  side.  By  this  arrangement  contour  may  be  secured 
in  the  picture. 

6.  The  unsteadiness  and  swaying  of  the  patient  may  be  obviated 


\Ji.ant.siif.Spne  ^ 


Fig.  56. — Tracing  Taken  by  the  Feiss  Apparatus.— (/V/jj-.) 


in  a  measure  by  placing  an  ordinary  photographer's  rest  against  the 
chest.  ^ 

Measurement  of  Photographs. — If  it  is  desired  to  measure  and  study 
the  curve  from  the  finished  photograph,  the  method  devised  by  Fitz 
is  of  value. ^  A  fixed  distance  is  decided  on  at  which  to  take  the  pictures. 
A  large  sheet  of  paper  is  then  divided  into  carefully  measured  squares 
of  any  desired  size.  This  sheet  of  paper  is  then  photographed  with 
the  camera  at  the  fixed  distance  to  be  adopted.  The  negative  will 
reproduce  the  diagram  on  the  paper,  each  square  on  the  negative  repre- 
senting in  measurement  the  square  upon  the  paper.  This  diagram 
on  the  negative  may  then  be  transferred  to  a  thin  sheet  of  clear  celluloid 

'  G.  W.  Fitz:  "Bos.  Med.  and  Surg.  Jour.,"  Nov.  16,  1905. 


RECORD    OF   SCOLIOSIS. 


73 


(_2 o_  Qf  a^n  inch  in  thickness)  by  scratching  with  a  needle-point  the 
Hnes  appearing  in  the  negative.     By  laying  this  transparent  scale  upon 
any  print  taken  at  this  fLxed  distance 
a  scale  of  measurement  is  provided. 

Tracing. — A  simple  and  approxi- 
mately accurate  record  may  be  made 
by  marking  the  spinous  processes  and 
laying  on  the  back,  while  the  patient 
stands  erect,  a  strip  of  crinoline  gauze, 
through  which  the  spinal  marks  may 
be  seen.  They  are  thus  easily  marked 
on  the  gauze,  which  may  be  kept  as  a 
record.  The  error  lies  in  the  possible 
slipping  of  the  gauze  and  the  necessity 
of  placing  the  hands  on  the  patient. 

Any  one  interested  in  the  sub- 
ject may  find  a  number  of  methods 
described,  together  with  the  liter- 
ature of  the  subject,  in  the  reference.^ 

Record  of  the  Rotation. — The 
method  of  Feiss  ^  is  fairly  accurate  and 
represents  the  simplest  available  means 
of  securing  a  record  of  rotation  in  the 
upright  position.  The  apparatus  con- 
sists of  a  square  upright  on  a  heavy 
base;  on  this  upright  slides  a  horizon- 
tal arm  carrying  two  arms  at  right 
angles  with  it,  all  pierced  with  holes 
two  inches  apart,  the  size  of  a  lead 
pencil.  The  patient  stands  in  the  ap- 
paratus, and  by  means  of  a  skin  pencil 
pushed  through  a  hole  on  each  side 
and  a  hole  at  the  back  of  the  sliding 
arm  three  marks  are  made  on  the  skin 
in  the  same  horizontal  plane.  These 
marks  are  first  made  at  the  level  of  the 

anterior  superior  spines,  and  then  the  sliding  arm  pushed  up  to  the  level 
of  the  deformity,  and  through  the  same  holes  three  similar  pencil  marks 
are  then  made  on  the  skin  at  that  level  and  at  other  levels  if  desired. 

^  "Ueber  die  Messmethoden  des  Riickens,"  Hovorka,  Wien,  1904. 
^  "Bos.  Med.  and  Surg.  Jour.,"  July  13,  1905. 


Fig.  57. — Apparatus  for  Recording 
Rotation'  in  Scoliosis. — {Fci'ss.) 


74 


EXAMINATION   AND   RECORD    OF   SCOLIOSIS. 


The  patient  now  steps  out  of  the  apparatus,  and,  by  means  of  a 
rubber  flexible  rule  or  a  lead  strip,  front  and  back  tracings  are  made 


Fig.  5S.— Leveling  App.'^ratus  (Nivellier  Trapez)  for  the  Measurement. of  Rota- 
tion IN  THE  Forward  Bent  PosiTiot^.—lScku/Zhess.) 


Fig.  59.— Schulthess'  Measuring  Apparatus. 


at  each  level  and  the  three  points""are  marked  on  the  tracings.     These 
tracings  are  then  drawn  on  a  paper,  the  corresponding  marks  on  each 


RECORD    OF    SCOLIOSIS. 


75 


outline  being  superimposed,  so  that  as  each  series  of  pencil  marks 
is  in  one  vertical  plane,  the  outlines  represent  a  series  of  superimposed 
contours  in  their  proper  relation  to  each  other. 

Rotation  may  be  estimated  in  degrees  with  accuracy  in  the  forward 
bent  position  by  means  of  the  Schulthess  level  square  (Nivelli'er  trapez) , 
which  consists  of  two  arms  sliding  on  a  rod  to  which  they  are  at  right 
angles.     These  arms  are  placed  on  corresponding  levels  of  the  back 


-Tracing  of  a  Left  Dorsal  Right  Lumbar  Curve  Made  bv  the  Schulthess 
Measuring  Apparatus. — {Children's  Hospital.) 


at  equal  distances  from  the  spine,  and  the  rod  is  provided  with  a  pro- 
tractor and  swinging  weight  to  show  the  inclination  of_^the  rod  to  the 
horizontal  plane  in  degrees  (Fig.  58). 

Methods  which  wculd  estimate  the  rotation  while  the  patientpies 
prone  on  the  face  are  inaccurate  because  the  pressure  of  the  table  on 
the  prominent  side  of  the  front  of  the  thorax  tends  to  rotate  the  chest 
and  cause  distortion. 


76  EXAMINATION   AND   RECORD    OF   SCOLIOSIS. 

The  Schulthess  Apparatus  for  the  Record  of  Scoliosis. — The 

Schulthess  apparatus,  which  is  generally  accepted  as  being  the  most 
accurate  means  of  record  at  our  disposal,  consists  of  an  upright 
frame  in  which  the  patient  stands,  the  pelvis  being  fixed  by  clamps 
and  the  sternum  steadied  by  an  adjustable  rod.  Behind  the  patient 
there  is  a  sliding  bridge  with  counterweights  which  move  up  and 
down  on  the  uprights.  Attached  to  this  bridge  is  a  pointer  which 
moves  forward  and  backward  and  sideways.  The  movements  of 
this  pointer  by  an  arrangement  of  weights  and  pulleys  are  recorded 
upon  two  glass  panels  parallel  to  the  sagittal  and  frontal  plane  of  the 
body  by  means  of  pencils  moving  on  paper  attached  to  the  glass  panels. 
By  tracing  from  below  upward  the  marked  lines  of  spinous  processes 
on  one  panel  the  anteroposterior  curve  of  the  spine  is  recorded,  while 
on  the  other  the  lateral  curve  is  simultaneously  marked. 

By  a  longer  pointer  the  lateral  body  outline  is  then  traced  in  the 
frontal  plane  after  the  position  of  the  scapulae  has  been  recorded.  The 
two  pencils  in  use  are  then  thrown  out  of  action,  and  by  means  of  a 
third  pencil  working  upon  a  glass  plate  on  the  sliding  bridge  horizontal 
contours  are  recorded  at  three  levels.  By  means  of  an  additional 
sliding  bridge  working  in  front  of  the  apparatus  a  late  modification 
of  it  provides  for  anterior  as  well  as  posterior  contours  which  may  be 
joined  to  give  a  complete  contour  of  the  body  at  different  levels  (Figs. 
59  and  60). 


Chapter  VI. 
PATHOLOGY. 

The  pathological  changes  found  in  scoliosis  are  not  the  result  of 
disease  of  the  bones,  but  are  modifications  in  shape  and  structure  result- 
ing from  abnormal  pressure  and  strain  in  a  growing  spinal  column. 

The  pathological  changes  occurring  in  scoliosis  may  vary  from  mod- 
erate asymmetry  to  extreme  distortion.  In  general  the  spine  is  curved 
to  one  side  in  some  part  of  its  length,  or  it  is  curved  in  one  direction 
in  one  part  and  in  the  opposite  direction  above  or  below  or  both  above 
and  below.  This  curve  is  formed  by  the  deviation  of  the  vertebrae 
from  the  median  sagittal  plane  of  the  body  and  is  more  marked  in  the 
column  of  bodies  than  in  the  column  of  arches.  The  lateral  curve 
may  be  a  general  sweep  to  one  side,  or  it  may  be  sharp  and  in  the  severer 
cases  angular.  In  the  severer  cases  it  exists  not  alone  in  the  presacral 
vertebrae,  but  may  also  involve  the  sacrum  and  coccyx. 

In  addition  to  the  lateral  deviation,  the  curved  region  is  rotated 
or  twisted  on  a  vertical  axis,  the  bodies  of  the  vertebrae  always  turning 
toward  the  convex  side  of  the  lateral  curve.  This  rotation  is  the  me- 
chanical accompaniment  of  the  lateral  curve,  and  one  cannot  exist 
without  the  other,  although  in  some  cases  the  rotation  is  out  of  propor- 
tion to  the  lateral  deviation,  and  in  other  cases  the  lateral  curve  pre- 
dominates over  the  rotation.  Pure  forms  of  wedge-shaped  and  lozenge- 
shaped  vertebrae  (to  be  described  below)  are  rare,  and  both  processes 
are  common  in  the  same  vertebra. 

In  connection  with  the  lateral  curve,  alteration  in  the  normal  antero- 
posterior physiological  curves  may  occur,  consisting  chiefly  of  an  in- 
creased or  diminished  dorsal  convexity.  W'Tiile  shghtly  developed 
scoliosis  leaves  the  physiological  curves  almost  unchanged,  with  scoliosis 
of  middle  degree  there  is  often  found  a  marked  flattening  of  the  dorsal 
spine,  and  in  severe  scoliosis  there  may  be  an  exaggerated  kyphosis  in 
the  segment  affected  by  the  lateral  deviation.  In  extreme  cases  there 
may  even  be  a  complete  reversal  of  lumbar  and  dorsal  anteroposterior 
curves,  for,  as  the  lateral  deviation  is  not  limited  to  any  one  segment, 

77 


Fig.  6!.— Scoliotic  Spink  from  the  Dwight  Collection  of  Abnormal  Spines  in  the 

Warren  Museum. 
Sacralization  of  the  twenty-sixth  vertebra    on  the  right.     Thirteen  dorsal  and    six  lumbar 
vertebrse.     Fusion  of  several  vertebra  and  of  first  three  ribs  on  the  left.     The  changes  in 
the  vertebral  bodies  are  characteristic  of  severe  scoliosis. 

78 


CHANGES   IN   THE    \'ERTEBR^. 


79 


neither  is  the  flattening  nor  the  formation  of  a  backward  prominence 
Hmited  to  the  points  of  physiological  kyphosis  or  lordosis.  The  relation 
of  these  changes  to  the  lateral  curve  is  but  little  understood. 

Such  being  the  gross  pathological  changes  occurring  in  the  spine  as  a 
whole,  it  will  add  to  clearness  in  considering  this  most  complex  matter 
to  take  up  individually  the  alterations  in  the  separate  elements. 


CHANGES  IN  THE  VERTEBR.^. 

Vertebral  Bodies. — The  scoliotic  vertebrse  are  to  be  divided  into 
two  classes,  according  to  their  pathological  changes,  those  in  the  angle 
of  the  curve  being  called  wedge  vertebrae,  while  those  between  the  apices 
of  the  curves  or  between  the  apices  and  the  normal  portion  are  called 
lozenge-shaped  or  oblique  vertebrae. 

A  certain  amount  of  rotation  and  also  a  transverse  displacement 
of  one  vertebra  upon  another  is 
normally  possible  up  to  a  certain 
degree  by  means  of  the  elasticitv 


Fig.  62. — A  "Wedge"  Vertebra. — 

{Schulthess.) 

Second   lumbar  seen   from   in   front ;    left 

lumbar  curve. 


Fig.    63. — An    "Oblique"    Vertebra. — 

(Schultliess.) 

Fourth  lumbar  seen  from  the  front ;  from 

a  left  lumbar  curve. 


of  the  intervertebral  discs  and  the  flexibility  of  the  ligaments,  but 
usually  the  pathological  process  is  not  satisfied  with  the  normal  ex- 
cursions, but  rotates  the  vertebra  in  its  structure.  This  rotation  is 
expressed  in  the  relation  of  the  upper  and  under  surfaces  of  the  verte- 
bral body  and  in  a  twist  between  the  body  and  arch. 

Wedge  Vertehrcv. — The  vertebrae  at  the  apex  of  the  lateral  curve 
and  just  above  and  below  it,  from  one  to  five  in  number,  are  called 
the  wedge  or  apex  vertebra;  (Keil-  or  Scheitelwirbel),  and  are  com- 
pressed on  one  side  and  consequently  wedge-shaped.  The  obliquity 
may  aft'ect  chiefly  the  upper  surface  when  the  vertebrae  are  below  the 
apex  of  the  curve,  and  the  lower  surface  chiefly  when  they  are  above  it, 
but  it  may  aft'ect  both  upper  and  lower  surfaces  nearly  equally,  as  in 


8o  PATHOLOGY. 

the  vertebra  at  the  point  of  the  curve,  and  some  modification  of  both 
surfaces  is  generally  to  be  noted.  The  thinnest  part  of  a  wedge  vertebra 
is  found  on  the  side  of  the  concavity  of  the  lateral  curve  and  generally 
toward  the  posterior  aspect  of  the  body.  The  side  of  the  body  toward 
the  concavity  is  broadened  and  lipped  in  severe  cases,  and  synostosis 
between  two  vertebral  bodies  may  occur  in  this  location.  As  a  whole, 
the  apex  vertebrae  are  rotated  toward  the  convexity  of  the  lateral 
curve. 

Lozenge-shaped  Vertebrce  (torsion  vertebrae,  oblique  vertebrae,  Inter- 
ferenz-  or  Schragwirbel). — The  vertebrae  between  the  apex  vertebrae 
of  the  two  curves  or  between  the  apex  vertebrae  and  normal  vertebrae 
are  deformed  in  a  somewhat  different  manner.  The  upper  surface 
of  the  vertebra  is  displaced  on  the  lower  in  such  a  way  that  the  outline 
of  the  vertebra  is  lozenge-shaped,  the  longest  diagonal  axis  being  toward 
the  apex  of  the  lateral  curve,  the  top  of  the  vertebra  being  shoved  side- 
ways on  the  bottom.  Such  vertebrae  may  show  oblique  ridges  on  the 
front  of  the  body.  The  upper  part  of  the  body,  moreover,  twists  on 
the  bottom  part,  below  a  right  dorsal  curve,  the  upper  part  of  the  verte- 
bra twisting  in  the  same  direction  as  would  the  hands  of  a  watch,  while 
above  the  apex  of  the  curve  the  twist  occurs  in  the  opposite  direction. 
This  is  called  longitudinal  torsion. 

The  vertebral  foramen  in  the  dorsal  region,  instead  of  being  round 
as  in  the  normal,  in  severe  scoliosis  becomes  pointed  at  the  end  toward 
the  concavity.  In  the  lumbar  region  the  normal  triangular  shape  is 
distorted  by  being  irregularly  blunted  at  the  angle  on  the  side  of  the 
concavity. 

Arches  of  the  Vertebrae. — Pedicles. — In  the  wedge  vertebra  the 
original  elevation  of  the  pedicles  may  be  retained.  As  a  rule,  they  are 
lowered  on  the  concave  side  of  the  ciurve  and  tend  to  be  more  oblique 
on  the  convex  side,  but  in  the  vertebra  at  the  point  of  the  ciurve  they 
may  be  alike  on  the  two  sides.  The  pedicle  on  the  convex  side  is 
directed  straight  backward  and  the  other  backward  and  outward. 
In  the  dorsal  vertebrae  the  pedicle  of  the  concave  side  may  be  narrowed, 
but  in  the  lumbar  region  it  is  more  generally  broadened  and  the  transverse 
process  becomes  smaller.  In  the  lozenge  vertebrae  below  the  apex  the 
pedicles  are  likely  to  be  depressed  and  above  it  elevated,  according  to  the 
intensity  of  the  curve.  In  severe  scoliosis  the  shortening  of  the  trunk 
is  so  great  that  the  vertebrae  are  pressed  together,  and,  as  the  bodies 
offer  less  resistance  to  compression  than  the  arches,  the  displace- 
ment of  the  pedicles  on  the  bodies  is  brought  about. 

Articular  Processes. — The  articular  processes  being  connected  with 


CHANGES   IN   THE   VERTEBR.E.  ,,/  8 1 

the  pedicles  share  in  any  change  that  they  undergo.  Owing  to  the  fact 
that  the  joint  planes  afe  so  different  in  the  dorsal  and  in  the  lumbar 
regions  the  pathological  appearances  differ  widely  in  the  articular  facets 
of  the  dorsal  and  lumbar  vertebrae.  The  crowding  together  of  the 
articular  processes  on  the  concavity  of  the  lateral  curve  results  in  an 
enlargement,  deepening,  and  broadening  of  the  joint  surfaces,  while 
on  the  convex  side  the  facets  are  smaller  and  higher.  In  the  lumbar 
region  the  superior  articular  facets  on  the  concave  side  are  hollowed 
out,  while  the  inferior  ones  are  correspondingly  prominent  and  rounded, 
and  the  cartilage  is  thickened  on  the  concave  side.  The  involvement 
of  these  joints  is  a  matter  of  some  practical  importance,  and  the  changes 
suggest  an  adaptation  to  greater  demands  on  the  joints  on  the  concave 
side  of  the  column.  Synostosis  may  occur  in  these  joints,  and  the 
ligaments  may  share  in  the  ossification. 

Transverse  Processes. — The  transverse  processes  tend  to  remain 
more  horizontal  than  the  body  of  the  affected  vertebra,  and  as  the  verte- 
bra becomes  inclined  to  the  horizontal  plane  by  the  changes  described, 
the  transverse  processes  strive  to  remain  as  nearly  horizontal  as  possible. 
As  a  result  of  this  the  transverse  processes  on  the  convex  side  above 
the  apex  are  elevated  and  below  it  depressed,  on  the  concave  side  above 
the  apex  they  are  depressed  and  below  it  elevated.  In  the  vertebra 
at  the  apex  of  the  curve  the  level  is  approximately  horizontal.  In  the 
lumbar  region  this  change  is  seen  in  its  most  marked  form,  so  that  in 
cases  of  severe  curvature  here  the  transverse  processes  may  point  almost 
straight  up  and  down.  Not  infrequently  the  transverse  processes  are 
shorter  and  thicker  than  normal  on  the  convex  side  above  and  below 
the  apex  of  the  curve. 

Spinous  Processes. — The  spinous  processes  are  directed  toward 
the  convexity  of  the  lateral  curve  in  the  dorsal  region.  This,  it  seems, 
may  be  explained  as  being  the  physiological  position  when  the  spine  is 
laterally  curved  and  is  retained  in  structural  scoliosis  imder  the  effect 
of  muscular  pull,  while  the  bodies  of  the  vertebrae,  being  influenced 
largely  by  weight  bearing,  an  individual  plasticity  of  bone,  and  certain 
unformulated  conditions,  are  forced,  as  has  been  said,  from  the  con- 
cavity to  the  convexity  Of  the  curve. 

In  the  lumbar  region  in  severe  cases  the  spinous  processes  are 
diverted  toward  the  concavity.  This  deviation,  it  would  seem,  is  the 
result  of  a  shoving  to  the  side  of  the  root  of  the  spinous  process  from 
extreme  rotation,  as  the  tips  of  the  processes  show  the  endeavor  to 
conform  to  the  physiological  position  by  being  in  some  degree  approxi- 
mated to  the  convexity  of  the  curve.  In  the  dorsal  region  the  spinous 
6 


82 


PATHOLOGY. 


processes  are  also  displaced  downward,  and  the  direction  of  each  spinous 
process  is  therefore  influenced  by  its  contact  with  the  one  below  it. 

The  angle  between  the  lower  border  of  the  spinous  process  in  this 
region  and  the  arch  becomes  on  the  convex  side  smaller  and  on  the  con- 
cave side  larger  than  normal,  and  the  appearance  of  displacement  to 
the  convex  side  is  thus  increased.  If  the  arch  is  displaced  horizontally 
upon  the  vertebral  body,  as  described  above,  by  the  lowering  of  one 
pedicle  and  the  elevation  of  the  other  the  spinous  process  undergoes 

a  rotation  around  its  own  longi- 
tudinal axis.  The  irregularity 
of  these  appearances  may  be  ex- 
plained by  the  pull  of  the  mus- 
cles, a  matter  which  is  at  present 
imperfectly  formulated. 

Joints  between  Vertebrae 
and  Ribs. — These  of  course  are 
of  two  kinds:  first,  the  joints 
between  the  heads  of  the  ribs 
and  the  sides  of  the  vertebra; 
second,  the  joints  between  the 
tubercles  of  the  ribs  and  the 
transverse  processes.  These  are 
both  similarly  afi"ected  in  severe 
scoliosis,  being  deepened  on  the 
side  of  the  convexity  and  faintly 
indicated  on  the  side  of  the  con- 
cavity, especially  above  the  apex 
of  the  cun-e.  The  articular  facets  on  the  side  of  the  vertebral  body  are 
moved  forward  on  the  concave  side  and  backv.-ard  on  the  convex  side. 


Fig.  64. —  Distorted  Anteroposterior 
Plane  of  a  Scoliotic  \'ertebra.— 
{Riedinger.) 


INTERVERTEBRAL  DISCS. 
These  show  the  earliest  changes,  and  at  the  points  of  greatest  curve 
are  compressed  and  project  beyond  the  edges  of  the  vertebral  bodies 
as  if  the  bodies  had  grown  into  them.     On  the  convex  side  they  are 
thicker  than  on  the  other. 


LIGAMENTS. 

On  the  side  of  the  concavity  the  anterior  common  ligament  is  dense 

and  thick,  while  on  the  convex  side  of  the  curve  it  is  thinned  and  shows 

no  definite  lateral  border.     In  the  lozenge-shaped  vertebra3  the  fibers 

run  obliquely  in  a  direction  corresponding  to  the  ridges  on  the  anterior 


CHANGES    IN   THE   MUSCLES.  83 

surface  of  the  vertebral  bodies.  The  posterior  common  ligament  near 
the  apex  is  found  more  to  the  convex  side  than  normal  because  its  in- 
sertions into  the  intervertebral  discs  do  not  share  in  the  broadening  out 
of  the  concave  side  of  the  vertebral  bodies,  and  the  vertebra  thus  grows 
to  the  concave  side  while  the  ligament  remains  more  nearly  in  the  middle. 
The  ligaments  connecting  the  heads  of  the  ribs  and  the  spine  are  long 
and  atrophied  on  the  convex  side  and  short  and  tense  on  the  concave 
side. 

MUSCLES. 

^^^lere  muscles  are  thrown  out  of  use  they  atrophy  and  may  undergo 
fatty  or  fibrous  degeneration.  When  increased  demands  are  made 
upon  them  they  hypertrophy.  When  under  changed  conditions  they 
pass  over  a  surface  of  bone  they  may  become  tendinous  where  the  con- 
tact occurs.  Nutritive  or  adaptive  shortening  occurs  when  the  ends 
of  muscles  are  approximated.  All  these  changes  are  to  be  found  in 
cases  of  severe  scoliosis,  but  the  muscular  changes  in  slight  scoliosis 
have  not  been  formulated.^ 

The  change  which  muscles  undergo  in  lateral  curvature  is  first  of 
all  a  change  of  direction  of  pull  caused  by  the  displacement  of  the  thorax 
in  relation  to  the  pelvis  toward  the  right  or  left.  For  example,  if  the 
trunk  is  displaced  toward  the  left,  the  muscles  taking  origin  from  the 
crest  of  the  ilium  are  directed  toward  the  left  at  their  insertion  in  the 
spine.  Under  normal  conditions  the  contractility  of  the  muscles  would 
be  sufficient  to  bring  them  back  to  their  normal  positions,  but  in  a  strong 
lateral  inclination  of  the  lumbar  segment  above  the  sacrum  the  psoas 
muscle,  for  example,  acquires  a  broad  insertion  and  becomes  fan- 
shaped,  thereby  assuming  a  different  function.  Under  normal  condi- 
tions the  insertion  of  this  muscle  is  more  linear  and  placed  at  an  acute 
angle  to  its  direction  of  pull. 

Following  the  loss  of  function  of  the  muscles  on  the  concave  side 
of  the  lateral  curve  in  severe  cases  fatty  degeneration  is  observed.  On 
the  convex  side  the  muscles  are  wasted  and  thin,  and  sometimes,  in 
exceptional  cases,  fatty  degeneration  is  found  here  also.  On  the 
convex  side  more  often  a  fibrous  degeneration  is  found;  that  is,  atrophy 
of  the  muscular  tissue  and  the  formation  of  larger  tendons. 

The  diaphragm  assumes  an  oblique  position  and  is  lower  on  the  side 
of  the  convexity  of  the  dorsal  curve.  If  the  apex  of  the  dorsal  cur\e 
is  situated  high  up  and  associated  with  kyphosis,  the  top  of  the  diaphragm 
may  be  much  elevated — even  as  high  as  the  level  of  the  third  rib. 

'  Phelps:    "Trans.  .-Vmer.  Orth.  Assn.,"  vol.  xiv. 


84 


PATHOLOGY. 


THORAX. 

In  lumbar  scoliosis  the  changes  in  the  thorax  are  slight,  but  some 
rotation  of  the  structure  as  a  whole  is  noted  in  relation  to  the  frontal 
plane  of  the  pelvis. 

In  dorsal  scoliosis  the  thorax  is  not  only  displaced  as  a  whole  toward 


Fig.   65. — Radiogram   of   Left  Scoliosis,  Resulting   from   Empyema   of   the   Right 
Side  with  Resection  of  the  Ribs. 


the  convexity  of  the  curve,  but  its  structure  is  distorted.  The  thorax 
as  a  whole  tends  to  retain  its  normal  position  with  regard  to  the  frontal 
plane  of  the  body  more  closely  than  does  the  spine,  which,  as  it  were, 
rotates  in  the  thorax.  It  thus  undergoes  a  twist  in  the  opposite  direction 
from  that  of  the  spine.  This  results  in  a  change  in  its  diagonal  diameters, 
by  which  the  one  from  the  side  of  the  convexity  behind  to  the  concavity 
in  front  is  lengthened,  and  the  corresponding  one  on  the  other  side  is 


CHANGES   IN   THE   THORAX. 


85 


shortened.  For  example,  in  right  dorsal  scoHosis  the  thorax  is  dis- 
placed to  the  right  and  becomes  prominent  on  the  right  side  behind 
and  the  left  side  in  front,  and  the  diagonal  diameter  from  the  right  side 
behind  to  the  left  side  in  front  is  lengthened.  As  a  result  of  this  the 
internal  surfaces  of  the  shafts  of  the  right  ribs  are  brought  nearer  to  the 
front  of  the  vertebral  bodies,  and  the  right  side  of  the  thorax  is  seriously 
diminished  in  capacity. 

Ribs. — The  ribs  on  the  convex  side  of  the  lateral  curve  show  a  back- 
ward increase  of  their  angularity,  forming  on  the  side  of  the  back  of  the 
thorax  a  more  or  less  sharp  and  prominent  ridge,  spoken  of  technically 


c'  'd  'i 

Fig.  66. — Thoracic  Ring  in  a  Right  Dorsal  Scoliosis,  seen  from  Abovk. — (Loretiz.) 


as  "the  rotation"  (Rippenbuckel).  In  compound  curves  of  the  dorsal 
region  these  phenomena  accompany  each  curve. 

From  the  angle  forward  to  the  sternum  the  ribs  of  the  convex  side 
show  a  loss  of  their  normal  curve.  The  ribs  on  the  side  of  the  con- 
cavity of  the  lateral  curve  show  a  straightening  of  their  angles  and  an 
increased  outward  bowing  of  their  shafts.  The  costal  cartilages  of  the 
concave  side  in  front  show  an  increased  curvature  forward  and  form 
on  the  front  of  the  chest  a  prominence  at  the  side  of  the  sternum  (vor- 
dere  Rippenbuckel). 

The  ribs  of  the  side  of  the  convexity  are  spread  apart  and  have 
a  more  oblique  direction;  on  the  side  of  the  concavity  they  are  closer 


00  PATHOLOGY. 

together  and  tend  to  a  more  horizontal  course.  These  phenomena 
are  dependent  upon  the  degree  of  inclination  of  the  part  of  the  spine 
to  which  the  ribs  are  attached. 

Sternum. — The  sternum  as  a  rule  deviates  but  little  from  its  normal 
position  and  direction  except  in  very  sen-ere  scoliosis.  The  variations  in 
position  consist — (i)  In  a  lateral  displacement;  (2)  in  an  obliquity  of  the 
lower  end,  which  turns  either  to  the  convexity  or  concavity  of  the  lateral 
curve;  (3)  in  a  rotation  around  its  longitudinal  axis,  making  one  lateral 
border,  commonly  the  one  toward  the  concavity  of  the  lateral  curve, 
more  prominent.  A  detailed  study  of  the  variations  of  the  sternum 
may  be  found  in  the  reference.^ 

SHOULDER-GIRDLE. 

The  marked  deformity  of  the  thorax  cannot  be  without  influence 
on  the  form  of  the  clavicles  and  scapulae.  The  scapula  undergoes, 
because  of  the  deformity,  various  changes  of  position  and  eventually 
of  form.  It  always  acquires  that  position  to  which  it  is  forced  by  the 
form  of  the  thorax,  the  weight  of  the  shoulder  and  arm,  and  the  tension 
of  its  muscles.  On  account  of  the  backward  prominence  of  the  thorax, 
the  scapula  is  moved  away  from  the  vertebral  column  on  the  convex 
side,  and  if  the  scoliosis  is  located  high  up  in  the  dorsal  region,  the  scapula 
moves  upward  also.  If  the  thorax  is  strongly  compressed  from  the 
side,  the  scapula  may  lie  sidewise,  so  that  its  dorsal  surface  has  a  lateral 
and  not  a  backward  direction,  or  it  may  swing  backward  so  that  its 
inferior  angle  crosses  the  line  of  spinous  processes  to  the  other  side. 
It  may  furthermore  acquire  a  strong  curve  on  itself  if  it  lies  on  a  thorax 
sharply  deformed,  and  become  convex  backward. 

The  clavicle,  whose  first  function  is  to  keep  the  scapula  at  a  certain 
distance  from  the  sternum,  also  changes  according  to  the  situation  of 
the  spinal  curve,  and  may  be  found  more  sharply  curved  in  scoliosis. 

PELVIS. 
Sacrum. — In  low  curves  (generally  convex  to  the  left  in  the  lumbar 
region)  the  sacrolumbar  junction  becomes  practically  the  apex  point, 
and  here  one  looks  for  rotation,  and  pressure  changes  may  continue 
the  curvatures  of  the  presacral  vertebrae.  The  sacrum  is  affected  in 
such  low  lateral  curves  in  a  way  analogous  to  that  of  the  other  vertebrae, 
but  modified  in  extent  by  the  fixed  position  of  the  sacrum.  In  a  right 
dorsolumbar  curve  the  following  changes  in  the  sacrum  were  found 
and  may  be  taken  as  exemplifying  them  (Schulthess) : 

^  Fauconnet:    "Zeitsch.  f.  orth.  Chir.,"  xvii,  page  201. 


CHANGES    IN   THE    PELMS. 


87 


1.  A  decrease  in  the  height  of  the  first  sacral  vertebra  on  the  concave 
side  {cj.  wedge  vertebra). 

2.  A  broadening  of  the  base  of  the  sacrum  on  its  concave  side  {cj. 
broadening  of  concave  side  of  vertebral  body). 

3.  Forward  displacement  of  the  left  or  concave  half  with  its  cor- 
responding ala  and  backward  displacement  of  the  right  or  convex  half 
{cj.  rotation  of  vertebral  bodies). 

4.  Broadening  of  the  part  of  the  sacrum  corresponding  to  the  pedicle 
on  the  concave  side. 

5.  Lowering  of  the  arch  on  the  concave  side. 

In  addition  to  this  there  is  to  be  seen  at  times  a  slight  indication 
of  a  lateral  curve  of  the  sacrum, 
reaching  its  apex  at  or  below  the 
middle  of  the  bone.  In  this 
the  coccyx  may  share,  empha- 
sizing the  curve,  but  the  sac- 
ral curve  is  most  easily  seen  by 
sighting  along  the  anterior  sur- 
face of  the  sacrum  or  looking 
down  the  vertebral  canal.  This 
curve  shows  slight  indications 
of  the  same  changes  noted  in 
the  presacral  vertebrae. 

The  pelvis  is  somewhat 
changed  in  diameter  and  shape 
in  severe  low  lumbar  curves  in 
which  the  sacrum  shows  dis- 
tortion. In  a  left  lumbar  curve 
the  diagonal  diameter  from  the 
left  side  behind  to  the  right  side 
in  front  is  greater  than  the  op- 
posite diagonal;  thus  in  an  individual  case  of  right  dorsal  left  lumbar 
curve  the  thorax  and  pelvis  would  be  twisted  in  opposite  directions. 


Fig.  67.— Oblique  Pelvis  Accompanying 
Scoliosis. — ( IVaireii  Museum,  cast  from 
a  specimen  in  Musei  DupuytreUy  Paris.) 


SKULL. 
In  long-continued  scoliosis,  especially  of  the  upper  part  of  the  column, 
asymmetry  of  the  face  and  skull  has  been  claimed  (Hoffa) ;  on  the  other 
hand  it  has  been  disputed  except  in  connection  with  congenital  tor- 
ticollis, asymmetry  of  congenital  origin,  and  in  rickets  (Schulthess). 


Ob  PATHOLOGY. 

INTERNAL  ORGANS. 

In  scoliosis,  especially  in  middle  and  severe  forms,  a  shortening 
of  the  trunk  is  apparent  which  prevents  the  normal  development  and 
function  of  the  internal  organs.  By  the  lateral  displacement  of  the 
trunk  and  rotation  of  the  thorax  the  pleural  and  abdominal  cavities 
become  distorted.  The  patients  become  anemic  and  show  a  certain 
disposition  to  tuberculous  pulmonary  diseases.  Bachmann,^  in  197 
autopsies  in  scoliotic  patients  of  moderate  and  severe  type,  has  found 
in  28.3  per  cent,  tuberculous  disease  of  the  lungs,  while  in  milder  degrees 
of  scoliosis  there  were  66  per  cent,  so  affected. 

The  secondary  changes  in  the  internal  organs  are  essentially  depend- 
ent upon  the  narrowing  of  the  containing  cavities.  In  a  severe  right 
dorsal  curve  the  right  pleural  cavity  is  very  much  narrowed — so  much 
so  that  in  extreme  cases  the  inner  surfaces  of  the  ribs  are  found  lying 
close  to  the  vertebral  column.  The  narrowing  of  the  pleural  cavity 
on  the  left,  that  is,  on  the  concavity,  is  not  so  important  as  that  of  the 
right.  It  follows  that  the  right  lung  must  suffer  from  the  distortion 
more  than  the  left.  Mosse^  found  apex  infiltration  in  60.2  per  cent, 
of  100  scoliotic  children  between  five  and  sixteen  years  old.  Kamine 
V.  Zade  ^  found  apex  affections  in  73  per  cent,  of  scoliotic  women,  the 
lung  affection  being  predominantly  of  the  lung  on  the  convex  side  of 
the  curve. 

Affections  of  the  pleura,  adhesive  pleuritis,  leading  to  total  oblitera- 
tion of  the  pleura  and  atelectasis,  are  found  very  frequently.  Bach- 
mann  gives  the  following  figures:  74.6  per  cent,  affections  of  pleura, 
with  7  per  cent,  of  total  obliteration  and  31  per  cent,  atelectasis  of 
lungs.  The  atelectasis  depends  either  upon  the  failure  of  the  respira- 
tory muscles  to  bring  about  expansion  of  the  lung  in  certain  places, 
or  upon  the  fact  that  a  real  compression  between  bony  walls,  or  between 
a  bony  wall  and  the  diaphragm,  has  taken  place.  This  compression 
is  more  readily  possible  if  certain  parts  of  the  lungs  are  held  back  by 
adhesion.  Bachmann  found  such  compression  in  24.3  per  cent,  of 
cases.  He  furthermore  gives  the  percentage  of  pneumonia  in  cases  of 
severe  scoliosis  as  22.8  per  cent. 

Undoubtedly  the  lungs  of  scoliotic  patients,  especially  in  cases  of 
kyphoscoliosis,  are  predisposed  toward  a  greater  number  of  diseases 
than  the  lungs  of  normal  individuals. 

^Bachmann:    "Bib.  med.,"  Abt.  1,  Heft  4,  1899. 
^  Mosse:   "Zeitsch.  f.  klin.  Med.,"  xli,  pp.  1-4. 
^Kamine  v.  Zade:    "Deut.  Arzte.  Zeit.,"  1902,  xx. 


CHANGES  IN  THE  INTERNAL  ORGANS.  69 

Heart  and  Vessels. — The  same  narrowing  of  thoracic  space  afifects 
the  heart.  It  is  frequently  found  pushed  upward  and  pressed  against 
the  anterior  chest-wall,  and  it  is  at  the  same  time,  according  to  the 
direction  and  the  extent  of  the  curvature,  more  or  less  displaced  later- 
ally. In  right  curves  generally  the  heart  is  displaced  tow^ard  the  left; 
but  this  is  not  a  constant  condition.  Hypertrophy  and  dilatation  of 
the  cavities  of  the  heart  are  very  frequent,  especially  of  the  right  heart 
in  severe  scoliosis.  Bachmann  found  it  in  56.4  per  cent,  of  cases, 
while  the  left  heart  was  similarly  affected  in  17.5  per  cent.  This  phe- 
nomenon was  found  in  both  right  and  left  sides  in  25.9  per  cent. 

The  aorta  in  general  follows  the  curvature  of  the  spine,  particu- 
larly in  right  curves.  In  a  left  dorsal  curve,  however,  the  aorta  does 
not,  as  a  rule,  lie  on  the  convex  side  of  the  curve,  but  runs  straight  like 
the  chord  of  an  arc,  more  often  in  front  or  even  a  very  little  to  the  right 
of  the  spine.  The  large  veins  show  less  typical  changes.  The  vena 
cava  in  the  region  of  the  liver,  where  it  is  relatively  fixed,  and  occasion- 
ally at  the  entrance  of  the  renal  veins,  may  show  a  change  in  its  course 
corresponding  to  the  change  of  position  of  the  organs. 

The  most  reasonable  explanation  for  the  hypertrophy  of  the  heart 
is  the  insuf&cient  depth  of  respiration  of  scoliotic  patients.  Even  in 
relatively  slight  distortion  of  the  thorax,  respiration  is  more  shallow 
than  the  normal,  consequently  the  right  side  of  the  heart,  in  order  to 
push  the  necessary  amount  of  blood  through  the  lungs,  must  do  an  extra 
amount  of  work. 

If  the  scoliosis  increases,  the  chest  space  is  restricted  still  more,  and 
the  expansion  of  the  lungs,  already  damaged  by  adhesions  and  thicken- 
ing, is  impeded.  The  heart  is  also  pressed  against  the  front  wall  of 
the  chest,  and  the  blood-pressure  is  changed  on  account  of  the  bends  in 
the  vessels,  which  conditions  add  greatly  to  the  work  of  the  heart.  The 
difficulty  which  the  blood  finds  in  passing  through  the  lungs  leads  to  a 
great  degree  of  venous  dilatation  if  the  condition  continues  long  enough. 
This  is  especially  noticeable  in  the  veins  of  the  head,  neck,  and  arms. 

Esophagus. — In  general  the  esophagus  has  a  tendency  to  deviate 
in  the  direction  of  the  concavity  of  the  curve,  although  frequently  its 
form  and  course  are  but  little  changed.  The  influence  upon  the  course 
of  the  esophagus  is  least  when  the  radius  of  the  curve  is  a  large  one 
and  the  secondary  curve  lies  below  the  diaphragm.  In  e\ery  case  the 
esophagus  follows  a  straighter  course  than  the  aorta,  and  it  crosses 
the  aorta  near  the  point  at  which  it  pierces  the  diaphragm.^ 

Intestines. — The  abdominal  contents  are,  in  consequence  of  re- 
'  Hacker:    "Wicn.  mod.  Woch.,"  1887,  page  46. 


90  PATHOLOGY. 

stricted  space,  pressed  downward  and  forward,  and  added  to  this  is  the 
influence  of  the  approximation  of  the  chest  to  the  pelvis  and  the  side 
displacement  of  the  vertebral  column.  The  downward  pressure  results 
in  crowding  the  intestines  into  the  true  pelvis.  The  lateral  displace- 
ment of  the  thorax  affects  chiefly  the  transverse  colon,  which  may  be- 
come almost  vertical. 

Liver. — In  right  curves  the  liver  is  pushed  toward  the  left,  the  left 
half  is  better  developed  than  the  right  half,  and  finally  the  organ  on  the 
right  side  may  be  indented  by  the  ribs. 

Kidneys. — In  right  dorsal  scoliosis  the  right  kidney  is  often  dis- 
placed upward  along  the  spine  and  the  left  one  downward,  and  while 
the  right  kidney  suffers  as  a  rule  slight  changes,  the  left  is  more  likely 
to  be  affected  severely  from  rib  pressure.  Cystic  degeneration  and 
floating  kidney  are  common.  Bachmann  enumerates,  among  i8o  ob- 
servations, 14  cystic  kidneys,  31  cases  of  granular  atrophy,  18  cases  of 
simple  atrophy,  and  6  cases  of  hydronephrosis. 

Spleen. — The  spleen  may  be  higher  than  normal.  Perisplenitis, 
atrophy,  and  cyanotic  induration  have  been  observed  (Bachmann). 

Stomach. — The  position  of  this  is  influenced  by  that  of  the  liver 
and  duodenum.  The  pylorus  is  depressed,  while  the  cardiac  end  gener- 
ally lies  high. 


Chapter  VII. 

ETIOLOGY— INFLUENCE  OF  SCHOOL  CONDITIONS. 

It  is  difficult  to  present  in  a  complete  yet  simple  form  the  manifold 
causes  of  scoliosis.  The  danger  of  confusion  lies  in  too  great  subdi- 
vision, to  which  the  subject  easily  lends  itself.  It  is  obvious  that  cases 
must  be  of  either  congenital  or  acquired  origin — further  than  this  the 
following  subdivisions  suggest  themselves : 

A.  Congenital  scoliosis. 

1.  Malformation  of  the  spine. 

2.  Malformation  of  the  scapula. 

3.  Malformation  of  the  thorax. 

B.  Acquired  scoliosis. 

1.  Anatomical,  physiological,  or  other  asymmetries  elsewhere  than 

in  the  spine. 

a.  Torticollis  (wry-neck). 

b.  Pelvic  asymmetry. 

c.  Pelvic  obliquity. 

d.  Unequal  vision. 

e.  Unequal  hearing. 

2.  Pathological  affections  of  the  vertebrae. 

a.  Rickets. 

b.  Osteomalacia. 

c.  Pott's  disease. 

d.  Dislocation. 

e.  Arthritis  deformans. 
/.   Tumors,  etc. 

3.  Pathological   affections  of  the   bones   and  joints  of  the  ex- 

tremities. 

a.  Diseases  of  bones  and  joints  of  the  leg. 

b.  Diseases  of  bones  and  joints  of  the  arm. 

4.  Distorting  conditions  due  to  disease  of  the  soft  parts. 

a.  Infantile  paralysis. 

b.  Spastic  paralysis. 

c.  Nervous  diseases. 

d.  Empyema 

e.  Organic  heart  disease. 
/.  Scars. 

g.  Throat  and  pulmonary  disease. 

5.  Habit  or  occupation  (school  scoliosis). 

91 


92 


ETIOLOGY INFLUENCE    OF    SCHOOL    CONDITIONS. 


A.  SCOLIOSIS  OF  CONGENITAL  ORIGIN. 

Scoliosis  due  to  congenital  defects  was  formerly  thought  to  be  a 
decidedly  rare  affection.  In  the  last  few  years  it  has  been  recognized 
that  it  is  much  more  common  than  was  supposed/  and  a  steadily  increas- 
ing number  of  cases  are  referred  to  a  congenital  origin,^  a  change  largely 

due  to  the  use  of  the  x-ray  and 
'  '^        the  more  accurate  study  of  the 

spine  thus  made  possible. 

I.  DUE  TO  MALFORMATIONS 
OF  THE  VERTEBRAL  COL- 
UMN. 

Scoliosis  may  occur  as  a  con- 
genital condition  in  connection 
with  severe  malformations,  such 
as  rachischisis  and  the  like,^ 
and  in  connection  with  "fetal 
rickets"  and  paralysis.^  It  oc- 
curs also  as  the  result  of  less 
severe  spinal  defects,  such  as 
cervical  ribs,^  spina  bifida,  and 
abnormal  formation  of  the  last 
lumbar  vertebra. 

Congenital  scoliosis  may  be 
evident — (i)  immediately  after 
birth,  as  in  the  case  of  the 
severest  malformations  (Col- 
ville^  in  1015  cases  of  new-born 
children  found  only  one  case  of 
scoliosis) ;  or  (2)  only  when  the 
child  begins  to  walk,  in  the  case  of  malformations  not  severe  enough 
to  cause  a  curve  in  the  recumbent  position.  In  these  latter  cases  the 
curvature  appears  as  the  result  of  the  superincumbent  weight  coming 
upon  the  defective  spine  or  as  the  result  of  asymmetrical  growth  due  to 

^  Liining  and  Schulthess:    "Ajlas  d.  orth.  Chir.,"  Miinchen,  1901. 
^  Atlianassow :    "Archiv  f.  orth.  Chirr,"  i,  3. 

^Schmidt:  "Allg.  Path,  und  path.  Anat.  d.  Wirbelsaule,"  Liibersch's  "Ergeb. 
zur  allg.  Path.,"  4.  Jahrg.,  1897. 

■'  Schuhhess  :   "  Joachimsthal's  Hdbch.  d.  orth.  Chir.,"  Jena,  1903,  iii,  708. 
^  Breuss  and  Kolisco,  quoted  by  Schuhhess. 
sColville:    "Rev.  d.  Orth.,"  1896,  7. 


Fig.  68. — Scoliosis  due  to  Congenital 
Defects  in  Spine  and  Thorax,  the 
Ribs  Being  Bifurcated  and  Defective. 


CONGENITAL    SCOLIOSIS.  93 

the  malformation.  Such  cases  as  these  are  perhaps  not  strictly  con- 
genital, but  might  be  better  spoken  of  as  scoliosis  due  to  a  congenital 
cause. 

The  two  most  common  locations  of  congenital  defects  are  in  the 
cervicodorsal  and  lumbar  regions.  In  the  former,  cervical  ribs  are  a 
frequent  accompaniment  (Halsrippenskoliose) .  The  formation  of 
a  cervical  rib  is  often  associated  with  a  splitting  of  the  vertebral 
bodies,  as  shown  by  the  x-ray,  and  in  some  cases  the  cervical  rib  is  ac- 
companied by  a  rudimentary  extra  vertebral  body.^  The  shoulder  on 
the  side  of  the  cervical  rib  is  elevated,  and  the  curve  is  a  sharp  cervico- 
dorsal one  with  a  compensatory  opposite  curve  below. 

In  the  lumbar  region  the  curve  is  frequently  associated  with  spina 
bifida,  spina  bifida  occulta,  or  sacralization  of  one  side  of  the  last  lumbar 
vertebra. 

Bohm^  has  called  attention  to  the, fact  that  numerical  variation  in 
the  vertebral  column  apparently  plays  a  part  in  causing  a  scoliosis 
really  of  congenital  origin,  but  not  necessarily  appearing  at  birth. .  In 
the  Dwight  collection  of  abnormal  spines  in  the  Warren  Anatomical 
Museum  there  are  three  that  show  a  scoliosis  apparently  resulting  from 
the  numerical  variation:  (i)  a  sacrolumbar  curve  to  the  left,  with  cau- 
dal variation  (see  chapter  on  Anatomy,  page  19),  and  union  of  the 
sacrum,  one  vertebra  higher  on  one  side;  (2)  dorsal  scoliosis  with  cranial 
variation  and  cervical  ribs  of  unequal  development;  (3)  dorsolumbar 
scoliosis  with  cranial  variation  and  fusion  of  the  last  three  lumbar  and 
first  sacral  vertebrae,  with  asymmetry  of  the  articular  processes  between 
the  eighteenth  and  nineteenth  vertebree.  All  these  scolioses  are  of 
comparatively  slight  extent. 

Clinically  he  found  from  :x;-ray  examination  in  16  out  of  24  cases  of 
"habitual  scoliosis,"  from  which  rickets  and  other  acquired  causes 
could  be  excluded,  types  of  variation  at  the  primary  seat  of  the  deformity 
present.  From  the  fact  that  numerical  variation  is  not  infrequently 
asymmetrical  in  the  spine  the  conclusion  is  presented  that  such  defects 
may  cause  scoliosis,  which  does  not  appear  until  the  beginning  of  the 
second  decade  on  account  of  the  fact  that  at  this  time  the  articular 
facets  undergo  a  change  in  character. 

Malformation  of  a  part  of  a  vertebra,  such  as  one  of  the  epiphyses, 
a  process,  or  a  part  of  the  arch,  will  lead  to  asymmetrical  growth,  which 

^Drehmann:  "Verhdl.  d.  Deutsch.  Gesell.  f.  orth.  Chir.,"  5th  Congress,  1906, 
page  12. 

^Bohm:    "Bos.  Med.  and  Surg.  Jour.,"  Nov.  22,  1906. 


94 


ETIOLOGY — INFLUENCE    OF    SCHOOL   CONDITIONS. 


may  disturb  mechanical  conditions  and  lead  to  scoliosis.     Abnormal 
curves  in  the  anteroposterior  plane  also  occur. 

2.  MALFORMATIONS  OF  THE  SCAPULA. 
Congenital  elevation  of   the   scapula    (Sprengel's    deformity)   will 
cause  a  scoliosis  which  is  usually  a  high  cervicodorsal  curve  with  com- 
pensating   dorsolumbar    curve, 
"   '  One  scapula  is  occasionally  ab- 

sent or  malformed  (Fig.  69). 

3.  MALFORMATION    OF   THE 
THORAX. 

Occasionally  great  irregu- 
larity characterizes  the  ribs  of 
one  or  both  sides.  Some  may 
be  bifurcated,  while  others  are 
deficient.  Such  irregularities 
are  a  cause  of  scoliosis. 

Heredity  must  also  be  con- 
sidered, as  it  is  known  that 
scoliosis  is  apparently  inherited 
in  some  families,  Schulthess 
estimating  that  from  10  to  15 
per  cent,  of  scolioses  are  heredi- 
tary. Congenital  defects  of 
form  can  be  inherited,  and 
would  reasonably  lead  to  sim- 
ilar forms  of  scoliosis,  while  an 
inherited  weak  skeleton  or  a 
disposition  to  rickets  would  not 
necessarily  lead  to  a  reproduction  of  the  form  of  scoliosis.  There  are 
cases,  however,  in  which  the  form  also  seems  to  be  hereditary. 


Fig. 


9. — Congenital    Elevation   of   the 
Scapula  Causing  Scoliosis. 


B.  ACQUIRED  SCOLIOSIS. 
Scoliosis  is  to  be  classed  as  acquired  when  the  deformity  comes 
on  after  birth  from  some  cause  not  apparently  congenital,  and  this 
includes,  so  far  as  we  know  now,  the  greater  number  of  cases.  It  may 
be  said  in  general  that  any  anatomical  or  physiological  condition  which 
causes  the  spine  to  be  held  habitually  curved  to  one  side  during  the 
period  of  growth  is  a  competent  cause  of  scoliosis,  and,  although  certain 


SCOLIOSIS    CAUSED   BY   ASYMMETRY.  95 

individuals  under  tiaese  conditions  will  escape  permanent  bony  defor- 
mity, certain  others  will  acquire  a  change  in  the  shape  of  the  spinal 
structure.  The  experimental  production  of  scoliosis  in  animals  has 
been  demonstrated  and  is  discussed  elsewhere  (page  42).  The  ac- 
quired varieties  of  scoliosis  may  be  considered  as  follows : 

I.  ANATOMICAL  OR  PHYSIOLOGICAL  ASYMMETRIES  ELSEWHERE 
THAN  IN  THE  SPINE. 

(a)  Torticollis,  or  wry-neck,  a  condition  characterized  by  the  con- 
traction of  one  sternocleidomastoid  muscle,  causes  a  tilted  and  twisted 
position  of  the  head  and  necessitates  a  compensatory  lateral  curve  of  the 
spine  to  preserve  the  balance  and  enable  the  head  to  assume  an  approx- 
imately normal  position.  Unilateral  torticollis,  if  sufficiently  long  con- 
tinued, is  always  accompanied  by  scoliosis. 

(b)  Asymmetry  of  the  Pelvis. — The  spine  is  not  always  located 
in  the  middle  of  the  pelvis,  but  at  times  is  found  at  one  side  of  the 
median  sagittal  plane  of  the  body  (amesiality  of  the  pelvis) .  The  pelvis 
may  be  in  other  respects  asymmetrical.  In  these  cases  a  compensating 
lateral  curve  is  necessary  in  order  to  allow  the  head  to  be  held  over  the 
center  of  the  body^  (Fig.  70). 

(c)  Obliquity  of  the  Pelvis. — Any  condition  which  causes  the 
pelvis  to  be  held  higher  on  one  side  in  the  horizontal  plane  is  a  com- 
petent cause  of  scoliosis,  because  such  obliquity  necessitates  a  lateral 
curve  of  the  spine  to  secure  normal  balance.  A  short  leg  must  be 
counted  a  frequent  cause  of  scoliosis.  But  it  must  be  remembered 
that  a  difference  in  the  length  of  the  legs  is  very  common  in  children,^ 
and  that  the  frequency  of  scoliosis  is  less  than  the  frequency  of  short 
legs.  The  association  of  short  legs  and  scoliosis  has  been  investigated, 
with  a  wide  variation  in  results. 

Sklifowsowsky 21  cases  of  scoliosis — 17  right  leg  longer. 

Staffel 230  cases  of  scoliosis — 62  left  shorter. 

H.  L.  Taylor 32  cases  of  scoliosis — 28  shorter  on  one  side. 

Lorenz 100  lumbar  scolioses — i  case  of  shortening. 

Dolega 200  scolioses — 2  cases  of  shortening. 

Schulthess  estimates,  without  analyzing  his  cases,  that  from  i  to 
5  per  cent,  show  this  association.  From  the  figures  quoted  it  may 
be  seen  that  there  is  no  agreement  in  the  matter,  and  that  it  must  be 
determined  by  the  careful  examination  of  large  groups  of  cases.  The 
measurement  taken  with  a  tape-measure  from  the  two' anterior  superior 

^  Barwell:   "Edin.  Med.  Jour.,"  Feb.,  1901;  "Brit.  Med.  Jour.,"  Feb.  4,  1899. 
'  Bradford  and  Lovett:   "Orth.  Surgery,"  3d  ed.,  page  476.  » 


96 


ETIOLOGV — INFLUENCE    OF    SCHOOL    CONDITIONS. 


spines  to  the  inner  malleoli  while  the  patient  lies  on  the  back  is  inexact 
and  of  little  value  as  determining  the  real  position  of  the  pelvis  in  stand- 
ing, and  too  much  importance  must  not  be  attached  to  it.  The  most 
reliable  method  that  we  have  of  determining  the  horizontal  plane  of 

the  pelvis  and  the  obliquity  which 
must  exist  when  there  is  really  a 


Fig.  70. — Scoliosis  due  to  Asym- 
metry of  the  Pelvis,  THE  Right 
Side  Being  Smaller. 


Fig.  71. — Left  Lumb.^r  Scoliosis 
from  Inequality  in  the  Length 
OF  THE  Legs. 


short  leg  is  to  place  a  level  on  the  two  anterior  superior  spines  when 
the  patient  stands  erect. 

As  an  example  of  the  little  value  to  be  attached  to  the  conventional 
measurement,  the  left  leg  may  be  one-quarter  of  an  inch  shorter  by  the 
ordinary  measurement  taken  while  lying  on  the  back,  yet  there  may 


CAUSES   OF   SCOLIOSIS.  97 

exist  a  flat-foot  on  the  right  side  which  does  not  appear  in  the  measure- 
ment and  when  the  patient  stands  may  lower  the  pelvis  a  half  inch  on  the 
right,  more  than  making  up  for  the  shortening  shown  by  measurement. 
It  is  not  an  uncommon  experience  to  find  that  the  spinal  curve  is  in- 
creased by  putting  a  block  under  the  foot  on  the  side  shown  to  be  short 
by  measurement,  but  that  the  spinal  curve  is  improved  by  making  the 
long  leg  longer  by  the  same  method. 

To  sum  up  the  facts  in  regard  to  a  short  leg  and  scoliosis:  The 
mechanical  aspect  would  lead  us  to  believe  it  a  likely  cause  in  certain 
cases.  The  observers  differ  widely,  and  the  ordinary  method  of  measure- 
ment is  inaccurate  and  often  misleading.  The  determination  of  the 
level  of  corresponding  points  on  the  pelvis  when  the  patient  stands  is 
the  most  reliable  method  of  measurement  at  our  command. 

(d)  Unequal  hearing  causes  a  tilting  or  tw^isting  of  the  head  which 
may  produce  lateral  cur\'ature  in  the  cer\-ical  and  upper  dorsal  regions. 

(e)  Unequal  vision,  necessitating  a  tilting  of  the  head  to  bring  ver- 
tical objects  into  clearer  vision,  may  cause  scoliosis.  It  has  been  claimed 
that  the  bad  postures  assumed  by  children  in  writing  are  of  ocular 
origin,  and  the  school  observations  at  Lausanne  are  of  interest  here, 
as  a  steady  increase  in  the  percentage  of  scoliotic  and  myopic  children 
was  found  from  the  lowest  classes  upward,  as  is  shown  by  the  table. 

Class. 

I 

II 

Ill 

IV 

V 

VI 

VII 


Scoliotic. 

Myopic. 

8.7  per  cent. 

3.0  per  cent 

18.2 

4-5 

19.8 

5-2 

27.2 

6.0 

28.3        " 

8.5        " 

32-4 

13-7 

31.0 

19.4 

The  relation  between  scoliosis  and  myopia  has  not  yet  been  determined. 
It  is  obvious  that  astigmatism  may  be  a  cause  of  head  tilting  and 
consequently  will  predispose  to  scoliosis.  The  subject  has  been  care- 
fully worked  out  by  Gould,^  whose  conclusion  is  that  in  asymmetrical 
astigmatism  the  axis  of  the  dominant  eye  determines  a  tilting  of  the  head 
to  the  right  or  left,  but  that  this  does  not  occur  in  symmetrical  astigma- 
tism. 

2.  PATHOLOGICAL  AFFECTIONS  OF  THE  VERTEBRA. 

(a)  Rickets,    a    constitutional   disease    affecting    young    children, 

causes  a  local  or  general  disturbance  in  the  normal  process  of  ossification 

^  G.  M.  Gould:  "Amer.  Medicine,"  Mav  21,  1904;  Mar.  26,  1904;  April  8, 
1005;  "N.  Y.  Med.  Record,"  .\pr.  22,  1895.'  H.  A.  Wilson  :  "N.  Y.  Med.  Jour- 
nal," June,  1906. 

7 


qS  etiology — INFLUENCE    OF    SCHOOL   CONDITIONS. 

of  the  bones,  whereby  the  epiphyses  become  enlarged  and  the  affected 
bones  soft  and  plastic.  Deformities  in  the  spine  occur  chiefly  in  the 
acute  stage  of  the  disease.  The  softening  of  the  vertebra?  causes  the 
column  to  collapse  symmetrically,  producing  kyphosis,  or  asymmet- 
rically, producing  scoliosis.  A  large  number  of  scolioses  originate 
directly  or  indirectly  from  rickets  (Fig.  123). 

The  severest  types  of  lateral  curvature  are  of  rachitic  origin.  They 
are  distinguished  by  a  shortening  of  the  trunk,  so  that  the  ribs  may 
meet  the  pelvis,  and  by  a  marked  deformity  of  the  thorax. 

(b)  Osteomalacia,  a  process  like  rickets  in  causing  a  softening  of 
the  bones,  but  more  frequently  seen  in  adolescents  and  adults,  is  accom- 
panied occasionally  by  lateral  curvature. 

(c)  Tuberculous  disease  of  the  spine,  or  Pott's  disease,  is  a 
destructive  pathological  process  attacking  the  bodies  of  the  vertebrae. 
Lateral  deviation  of  the  spine  associated  with  stiffness  and  very  slight 
rotation  often  exists  in  connection  with  the  backward  "hump"  or 
kyphosis,  which  is  the  characteristic  sign  of  the  disease. 

(d)  Severe  injuries  of  the  spine,  resulting  in  chronic  sprain  of  the 
vertebral  column,  dislocation  of  the  vertebrae,  and  injury  of  the  epi- 
physeal cartilage,  may  be  accompanied  by  lateral  deviation  of  the  spine 
as  a  symptom. 

(e)  Arthritis  deformans  is  characterized  by  a  progressive  stiffening 
of  the  spine  due  to  deposits  of  newly  formed  bone  on  the  front  and  sides 
of  the  column,  binding  the  vertebrae  together.  The  intervertebral 
discs  degenerate  and  the  vertebrae  become  fused;  bony  deposit  occurs 
in  the  ligaments,  and  the  articulations  of  the  vertebra  with  the  ribs 
may  lose  some  or  all  motion.  Lateral  deviation,  accompanied  by 
general  kyphosis,  may  result. 

Other  causes  of  this  class  are  tumors  of  the  spine  and  hereditary 
syphilis.  The  scolioses  of  this  class  are  symptomatic  of  a  serious  con- 
dition, and  except  for  that  of  rickets  are  not  to  be  treated  like  ordinary 
primary  scolioses  and  would  be  much  injured  by  such  treatment. 


3.  AFFECTIONS  OF  THE  BONES  AND  JOINTS  OF  THE  EXTREMITIES. 

(a)  Diseases  of  the  bones  and  joints  of  the  lower  extremity  play 
a  larger  part  in  the  etiology  of  scoliosis  than  those  of  the  arm  and  shoulder. 
Lateral  curvature  may  be  caused  by  the  shortening  of  one  leg,  due  to 
derangement  of  growth;  to  unilateral  diseases  of  the  hip-joint  causing 
shortening,  dislocation,  contraction,  or  ankylosis  in  a  position  of  adduc- 
tion, abduction,  or  flexion;    to  unilateral  congenital  or  paralytic  dis- 


PARALYTIC    SCOLIOSIS. 


99 


location  of  the  hip;  to  coxa  vara,  coxa  valga,  and  fractures  of  the 
lower  extremity;  to  diseases  and  malformations  of  the  diaphyses  of  the 
leg  or  thigh  bones ;  to  diseases  of  and  operations  on  the  knee-joint  causing 
shortening,  contraction  in  the  flexed  position,  or  knock-knee  on  one 
side;  and  to  diseases  and  malpositions  of  the  foot,  especially  flat-foot. 
Scoliosis  due  to  a  shortening 
of  one  lower  extremity  is  fre- 
quently spoken  of  as  "static 
scoliosis." 

(b)  Diseases  of  the  shoul- 
der-joint, causing  partial  or 
complete  ankylosis,  may  be  ac- 
companied by  a  curve  of  the 
spine  in  the  dorsal  region. 

4.  DISTORTING  CONDITIONS 
DUE  TO  DISEASE  OF  THE 
SOFT  PARTS. 

(a)  Infantile  spinal  par- 
alysis or  anterior  poliomye- 
litis is  a  fairly  common  cause 
of  lateral  curvature.  It  occurs 
during  the  second  dentition  in 
children,  although  adults  show 
the  later  changes.  The  lower 
extremity  is  more  often  affected 
than  the  upper.  The  deformi- 
ties produced  are  due  to  shorten- 
ing of  bone  or  to  muscular  par- 
alysis. Scoliosis  results  in  one 
of  three  ways: 

1.  From  inequality  in  the 
length  of  the  legs,  causing  a  tilt- 
ing of  the  pelvis. 

2.  From  unilateral  paralysis  of  the  muscles  directly  controlling 
the  vertebral  column,  which  may  cause  a  deviation  of  the  spine  either 
to  that  side  or  to  the  other  side.  It  does  not  follow,  as  shown  by  x^rnd 
experimentally  and  as  recognized  clinically  by  others,  that  a  paralysis 
of  the  muscles  of  one  side  of  the  back  is  followed  by  a  curve  convex 
toward  the  paralyzed  muscles,  as  would  naturally  be  expected.  The 
curve  is  the  result  of  the  effort  of  the  patient  to  adjust  his  center  of 


F"iG.  72. — Right  Doksal.Curve  Due  to  Lv- 
FANTiLE  Paralysis. 


lOO 


ETIOLOGY — INFLUENCE    OF    SCHOOL    CONDITIONS. 


gravity  to  the  new  conditions  induced  by  unilateral  paralysis.  This 
equilibration  may  result  in  a  curve  convex  either  to  the  right  or  left  in  a 
right-sided  paralysis. 

3.  From  faulty  spinal  attitudes  assumed  in  consequence  of  paraly- 
sis elsew^here,  as  in  paralysis  of  the  arm. 

(b)  Spastic  paralysis  or  Little's  disease  in  general  is  the  result  of  a 
cerebral  lesion  and  a  descending  degeneration  of  the  lateral  columns 


Fig  73.— Hysterical  Scoliosis. 


Fig.  74. — Right   Dorsal  Curve  dl'e 
TO  Left  Empyema. 


of  the  spinal  cord.  The  growth  of  bones  is  often  retarded,  and  mus- 
cular irritability  and  stiffness  are  noted  with  contractions.  Scoliosis 
is  an  occasional  accompaniment. 

(c)  Other  nervous  diseases,  represented  by  a  much  smaller  number 
of  cases  of  lateral  curvature,  are  multiple  neuritis,  meningitis,  cerebro- 
spinal meningitis,  syringomyelia,  pseudomuscular  hypertrophy,  loco- 
motor ataxia,  Friedreich's  ataxia,  tumors  of  the  spinal  cord,  and  obstetrical 
paralysis.     Lumbar  neuritis  gives  rise  to  a  lateral  curve  which  is  rather 


HABIT    SCOLIOSIS.  lOI 

an  anomaly  of  position  than  a  true  scoliosis  and  is  called  ischias  scolio- 
tica}  A  similar  malposition  is  observed  in  hysteria^  (Fig-  73)-  An 
analogous  malposition  is  found  in  sacro-iliac  disease  in  which  the  lateral 
curve  is  induced  by  the  instinctive  effort  to  spare  the  affected  joint. 

((/)  Empyema  is  followed  by  lateral  curvature  in  certain  cases, 
both  without  operation  and  after  the  operation  for  removal  of  a  rib. 
The  scar  contraction  seems  to  be  the  cause  of  the  deviation,  which 
is  always  to  the  right  in  left  empyema  and  vice  versa. 

{e)  Scars  rarely  cause  scoliosis,  although  it  sometimes  is  found  after 
extensive  burns  when  the  deviation  of  the  spine  is  brought  about  by 
contraction  of  the  scar  tissue. 

(/)  Phthisis  and  diseases  of  the  pleura  and  obstructions  in  the 
nasopharynx  are  to  be  mentioned  among  the  diseases  of  the  respiratory 
organs  sometimes  followed  by  scoliosis. 

C?)  Organic  heart  disease,  especially  in  children,  is  a  competent 
cause  of  lateral  curvature. 

S.  HABIT  OR  OCCUPATION. 

A  large  number  of  scolioses  are  observed  which  cannot  be  attributed 
to  congenital  malformation  nor  to  the  direct  or  indirect  results  of  the 
pathological  process  of  disease.  Some  apparently  have  their  cause  in 
an  habitual  or  frequent  malposition  necessitated  by  the  occupation  of 
the  individual,  and  these  are  to  be  classed  as  habit  or  occupation 
scolioses. 

In  adults,  habit  or  occupation  scoliosis  is  attributed  to  the  habitual 
and  compulsory  maintenance  of  one  position  for  long  periods  of  time, 
as  is  required  in  certain  occupations.  In  these  cases  the  form  and 
extent  of  the  lateral  deviation  are  determined  by  the  form  of  faulty  pos- 
ture. On  account  of  relative  plasticity  of  bone  and  periods  of  rapid 
growth,  accompanied  by  lax  muscular  tone,  children  are  especially 
subject  to  deformities  of  attitude  and  are  particularly  liable  to  acquire 
habit  scolioses.  Common  causes  of  scoliosis  in  children  are  faulty 
attitudes  in  sitting  and  in  standing,  the  former  favored  by  improper 
school  furniture,  and  the  latter  by  an  arrangement  of  the  clothing 
almost  universally  bad,  which  will  be  discussed  elsewhere.  Typical 
instances  are  found  in  violin  playing,  riding  horseback  on  a  side  saddle, 
carrying  heavy  weights  asymmetrically,  as  children  on  the  arm,  heavy 

'  Bahr:  "Zentralbl.  f.  Chir.,"  1896,  14;  Ehret:  "jNIitt.  aus  d.  Grcnzgcb.  d. 
Med.  und  Chir.,"   iv,  5. 

'Binswanger:  'Hysterical  Scoliosis,"  "Deutsch.  mcd.  Wochens.,"  \'ereinsbcil., 
1902,  5. 


I02  ETIOLOGY — INFLUENCE    OF    SCHOOL    CONDITIONS. 

baskets,  and  heavy  bundles  of  paper  supported  by  a  strap  over  one 
shoulder. 

It  may  be  considered  as  possible  that  the  bulk  of  all  scolioses,  tak- 
ing mild  and  severe  cases  together,  is  an  "occupation"  scoliosis  ac- 
quired by  faulty  attitudes  at  school  and  elsewhere;  but  this  does  not 
answer  the  question,  because  all  children  are  subject  to  these  conditions 
and  only  a  part  develop  scoliosis.  As  a  rule,  the  children  affected  are 
of  less  vigorous  build  and  of  slightly  poorer  physique  than  those  who 
are  not  affected.  Severe  scoliosis  accompanied  by  marked  rotation  in 
children  is  generally  due  to  congenital  malformation  of  the  spine, 
rickets,  empyema,  or  infantile  paralysis.  Any  account  of  the  etiology  of 
scoliosis  would  be  very  incomplete  which  did  not  make  it  perfectly 
clear  that  in  many  cases  of  the  deformity  the  surgeon  must  be  content 
to  leave  the  cause  not  satisfactorily  accounted  for. 

School  Fatigue.^ — -A  correct  attitude  is  dependent  upon  the  tone 
and  strength  of  the  muscles  by  which  the  upright  posture  is  maintained, 
so  that  any  cause,  such  as  fatigue,  which  lowers  the  muscular  tone,  has 
a  bearing  in  this  connection. 

Mental  Fatigue. — Muscles  become  relaxed  not  alone  by  physical 
but  by  mental  exertion  and  mental  fatigue.^  Mental  work  is  at  first 
stimulating,  but  if  continued  for  a  long  time,  especially  concentrated  on 
one  topic,  will  produce  both  mental  and  bodily  fatigue. 

Continuous  mental  labor,  though  of  only  short  duration,  will  produce  a  greater 
degree  of  fatigue,  and  that  more  quickly,  than  the  same  amount  of  work  interrupted 
by  brief  intervals  of  rest.  A  change  of  work,  particularly  from  a  hard  to  an  easy 
subject,  will  afford  the  same  relief  as  a  short  rest.  Severe  fatigue  comes  on  -n-ith 
great  regularity  in  periods  of  the  ancient  languages  and  mathematics,  while  recu- 
peration takes  place  during  history,  geography,  and  nature  study.  The  modern 
languages  occupy  a  middle  place;  singing  and  drawing  make  rather  great  demands 
on  those  who  do  well  in  these  branches.  After  violent  or  prolonged  exercise  one 
is  less  fit  for  study,  but  after  moderate  exercise  intellectual  work  seems  to  become 
easier.  The  proper  relation  between  physical  and  intellectual  work,  in  'order  to 
obtain  the  greatest  good  from  each,  is  a  question  which  should  receive  the  careful 
consideration  of  educators. 

Exhaustion  in  Children. — One  of  the  first  ways  in  which  fatigue  shows 
itself  is  in  the  slight  amount  of  force  expended  in  a  movement  and  frequently  a 
lessening  in  the  number  of  movements.  In  extreme  exhaustion  the  ordinary 
movements  are  not  excited  by  ordinary  stimuli,  and  such  as  do  occur  are  slow  and 

1  Schanz:  "Schule  und  Skoliose,"  "Zeitsch.  f.  orth.  Chir.,"  x^-ii,  170;  Kron- 
ecker:  "Ueber  die  Ermiidung  und  Erholung  der  gest.  Muskeln, "  Leipzig,  1871; 
Mosso:  "Fatigue,"  "International   Science   Series." 

^Sikorsky:  "Sur  les  effets  de  la  Lassitude  provoquee  par  les  travaux  intel- 
lectuals chez  les  enfants  de  I'age  scolaire";  Leo  Burgerstein:  "Die  Arbeitskurve 
einer  Schulstunde" ;  Hugo  Laser:  "  Ueber  geistige  Ermiidung  beim  Schulunterrichte." 


SCHOOL   FURNITURE.  I03 

labored.  This  may  be  accompanied  by  irritability  and  occasional  jerky  movements 
not  controlled  by  circumstances.  The  eyes  may  wander  and  not  be  distinctly 
fixed  by  the  sight  of  the  objects  around;  the  face  becomes  toneless  and  devoid  of 
expression;  there  may  possibly  be  a  fullness  under  either  eye.  Frequently  there 
is  manifest  an  asymmetry  of  posture  and  movement.  The  head  is  held  on  one 
side;  the  arms  when  extended  are  not  horizontal — usually  the  left  one  is  lower;  the 
hand  balance  is  weak;  that  is,  when  hands  and  arms  are  held  straight  out  in  front, 
the  fingers  and  wrists  are  not  extended,  and  the  thumb  is  not  on  the  same  plane 
as  the  fingers;  this  also  is  more  marked  in  the  left  hand.  Lack  of  muscular  tone 
shows  itself  in  a  "slumped"  position  either  standing  or  sitting.  The  face  may  be 
lengthened  from  relaxation  of  the  muscles  and  falling  of  the  jaw.  Sighing  and 
yawning  are  common  symptoms.  Speech  is  slow,  and  the  tone  of  the. voice  altered, 
and  in  general  there  are  slowness  and  inaccuracy  of  mental  response. 

School  Furniture. — It  is  obviously  important  to  furnish  school  chil- 
dren with  seats  and  desks  which  do  not  favor  improper  attitudes  in 
sitting  and  writing.  The  figures  show  that  scoliosis  is  a  constantly 
increasing  affection  during  school  life,  and  it  is  a  matter  of  common 
information  that  "school  scoliosis"  and  round  shoulders  are  frequent  in 
school  children.^  In  1842  Barnard,  of  Hartford,  published  an  article 
on  the  subject,  followed  twenty  years  later  by  Fahrner,^  of  Zurich, 
Meyer,^  Cohn,*  Schenk,  Lorenz,'^  Schulthess,^  and  Scholder."  The 
most  practical  study  of  the  matter  made  in  late  years  was  undertaken 
by  the  Boston  Schoolhouse  Commission,*  and  use  will  be  made  of  their 
report  in  this  section. 

The  two  things  to  be  prevented  in  school  furniture  are — (a)  the  pro- 
longed stretching  of  the  back  muscles  by  the  continued  maintenance 
of  flexion  of  the  spine,  and  (b)  the  assumption  of  distorted  and  twisted 
attitudes,  children  with  tired  muscles  tending  to  rest  them  by  assum- 
ing a  change  of  position.  Furniture  of  bad  design  or  improperly  fitted 
tends  to  favor  both  of  these. ^ 

A  large  number  of  desks  and  seats  have  been  devised;  it  is  said  that 
150  have  been  proposed,  but  at  least  over  30  have  been  tried.  The 
chair  ^^  devised  for  the  Boston  Schoolhouse  Commission  in  1903,  which 

^  Scudder:     "Determination  of   the  Muscular   Strength   in    Growing   Girls," 
"Bos.  Med.  and  Surg.  Jour.,"  Nov.  6,  1890. 
^  "Das  Kind  u.  d.  Schultisch,"  1865. 

^  "Die  Mech.  des  Sitzeijs,"  "Virch.  Arch.  f.  path.  Anat.,"  x.xxv,  1S67. 
^"Beitr.  zur  Losung  der  Subsellenfrage, "  Berlin,  1885. 
^  Lorenz:    "Ueber  die  Skol.,"  Wien. 
"  Schulthess:   "Zeitsch.  f.  orth.  Chir.,"  1892,  i,  i. 
'  "Archiv  fiir  Orth.,"  i,  2. 

^  Boston  Schoolhouse  Commission  Reports  for  190 1-5. 
'Feiss:    "Cleveland  Med.  Jour.,"  Aug.,  1905. 
^"Reports  of  Boston  Schoolhouse  Commission,  1903,  1904,  1905. 


I04 


ETIOLOGY — INFLUENCE    OF    SCHOOL   CONDITIONS. 


was  carefully  worked  out  by  Dr.  F.  J.  Cotton  in  the  Scoliosis  Clinic 
of  the  Children's  Hospital,  will  be  here  considered  as  embodying  the 
theoretical  requirements  and  as  having  worked  well  on  rather  a  large 
scale  in  some  years  of  practical  use,  there  being  22,000  such  seats  now 
in  use  in  Boston  public  schools.  The  theoretical  requirements  which 
are  by  common  consent  accepted  will  be  first  discussed. 

1.  The  height  of  the  seat  from  the  floor  should  be  such  that  in  sit- 
ting the  feet  rest  on  the  floor.  Too  high  a  seat  produces  pressure  on 
the  back  of  the  thighs;  too  low  a  seat  induces  flexion  of  the  lumbar  spine. 

2.  The  slope  of  the  seat  should  be  backward  and  downward  about 
three-eighths  of  an  inch.  The  depth  of  the  seat  should  be  about  two- 
thirds  the  length  of  the  thisrhs. 
The  width  of  the  seat  should 
be  that  of  the  buttocks.  Some 
concaving  of  the  seat  is  com- 
fortable, but  not  essential. 

3.  The  hack  of  the  seat 
should  have  a  slope  backward 
of  one  in  twelve  from  the  ver- 
tical line  (Saxon  'regulations). 
The  more  modern  expression 
of  this  is  found  in  two  back 
supports,  one  low  down,  ^  to  i 
inch  in  front  of  the  back  edge 
of  the  seat,  and  a  second  higher 
up,  i|-  inches  behind  the  back 
edge  of  the  seat.  In  the  experi- 
mental .  study  of  school  seats 
alluded  to  it  Avas  found  that  in 

a  nearly  balanced  sitting  position  a  relatively  low  back  support  was 

ample  and  the  upper  one  not  required. 

4.  The  height  of  the  desk  should  be  such  that  the  back  edge  allows 
the  forearm  to  rest  on  it  naturally  with  the  elbow  at  the  side.  The 
height  of  this  edge  from  the  edge  of  the  seat  is  known  technically  as  the 
"difference." 

5.  The  slope  of  the  desk  has  been  advocated  at  all  angles  from  o  to 
45  degrees.  The  theoretically  best  slope  for  reading  is  at  least  30 
degrees,  but  this  is  practically  too  steep  and  books  slide  off,  and  it  is  not 
practicable  for  writing.  From  10  to  15  degrees  is  the  usually  accepted 
inclination.     The  proper  distance  of  the  eyes  from  the  desk  is  from  12 


Fig.  75. — Boston  School  Desk  and  Chair. — 
{Boston  Schoolhouse  Commission.') 


SCHOOL   FURNITURE.  ■  I05 

to  14  inches.  The  width  of  the  desk  is  immaterial,  22  to  24  inches 
being  the  usual  size. 

Two  separate  models  for  back  rests,  one  for  older  and  one  for 
younger  children,  were  worked  out  independently  by  means  of  modelling 
wax  and  wood,  and  the  curves  of  the  two  were  found  to  be  practically 
identical.  A  third  model  for  adolescent  girls  was  later  found  necessary 
on  account  of  the  larger  hips,  and  was  slightly  higher,  with  flattened 
lower  corners.  The  description  of  the  back  rest  for  the  middle  group 
is  given  here.^ 

"  The  model  finally  settled  on  consists  of  a  curved  support  of  wood, 
nine  and  three-quarters  inches  wide  and  five  inches  high,  with  a  con- 
cavity of  one  inch  in  depth  from  side  to  side,  with  a  convexity  of  one 
inch  in  profile,  the  whole  very  slightly  tilted  backward.  The  maximum 
convexity  lies  one-third  of  the  way  up,  and  when  properly  adjusted 
comes  about  opposite,  or  a  little  above,  the  fourth  lumbar  vertebra. 
This  support  is  carried  on  a  light  casting,  running  in  the  groove  of  a 
single  cast-iron  upright  attached  to  the  back  of  the  seat.  A  set-screw 
fixes  the  height  after  adjustment. 

"  Seats  have  been  manufactured  from  these  models  in  two  sizes,  and 
are  used  with  adjustable  desk  and  seat  castings  that  provide  for  height 
and  adjustment.  As  the  matter  stands,  the  new  furniture  provides  a 
seat  adjustable  for  height,  with  the  new  back  rest  also  adjustable  for 
height,  and  a  desk  likewise  provided  with  a  vertical  adjustment. 

"As  to  the  distance  from  the  seat  to  the  desk,  the  vertical  writing 
system  calls  for  such  a  space  as  shall  let  the  hand  come  down  nearly  to 
the  edge  of  the  desk  without  the  elbow  striking  the  back  support, 
namely,  a  distance  from  seat-back  to  desk-edge  equal  to  the  length 
from  wrist  to  elbow.  This  brings  the  desk-edge  pretty  close  to  the 
body  in  comfortable  writing  position. 

"This  arrangement  makes  it  possible  to  write  freely  and  easily 
with  the  body  pretty  evenly  balanced,  or  even  leaning  backward 
slightly.  With  the  desk-edge  so  close  the  pupil  is  rather  cramped  and 
in  poor  position  for  reading.  The  compromise  usually  made  is  to  have 
the  desk  a  few  inches  further  forward;  this  is  well  for  reading,  but  for 
writing  this  requires  a  forward  sitting  position  which  is  undesirable, 
because — (a)  the  back  loses  its  support,  (b)  the  supporting  of  weight  on 
the  arm  tends  to  rotated  postures  of  the  spine,  (c)  the  posture  tends 
to  round  shoulders,  and  (i)  the  posture  tends  to  bring  the  eyes  too 
close. 

"For  these  reasons  it  is  desirable  to  be  able  to  have  an  adjustment 
'  F.  J.  Cotton:    "American  Phys.  Education  Review,"  Dec,  1904. 


Io6  ETIOLOGY INFLUENCE    OF    SCHOOL    CONDITIONS. 

to  give  a  writing  and  a  reading  distance  to  desk  from  chair  to  suit  the 
occasion.^ 

"This  adjustment  should  have  a  range  of  at  least  four  or  five  inches. 
In  the  avoidance  of  vicious  attitudes  this  adjustment  is  of  the  utmost 
importance,  and  a  surprising  amount  has  been  written  in  regard  to 
positive,  negative,  and  nil  'distance.'^  With  the  'distance'  ad- 
justable we  have  plenty  of  room  to  move  about  and  an  easy  supported 
position  for  reading,  and,  for  wTiting,  a  good  position  with  a  minimum 
tendency  to  lean  forward  or  twist,  and  with  a  support  to  the  lower  back 
that  works  against  distortion.  With  no  single  position  can  all  these 
things  be  attained."^ 

Writing  Position. — Of  late  years  there  has  been  a  tendency  to  blame 
the  teaching  of  slanted  handwriting  for  much  of  the  scoliosis,  and  the 
teaching  of  vertical  writing  was  substituted,  the  patient  sitting  squarely 
in  front  of  the  desk  and  writing  vertically,  with  a  view  of  avoiding  the 
distorted  position  incidental  to  slanted  handwriting.  Statistics  have 
.been  reported  in  favor  of  the  vertical  system.     These  are: 

Percentage  of  Scoliotics. 

In  Slanted  Writing.  In  Vertical  Writing. 

Nuremburg 24  15 

Zurich 32  12 

Miinich 24  15 

Fiirth 65  31 

Wurzburg 28  8 

To  these  figures  must  be  attached  considerable  importance,  but  the 
question  is  by  no  means  settled,  Gould,  of  Philadelphia,  having  called 
attention  to  certain  factors  previously  overlooked. 

"With^  the  head  and  body  erect,  the  paper  straight  before  the  me- 
dian line  of  the  body,  and  the  penholder  held  as  commanded,  no  person 
can  or  will  write,  for  the  simple  reason  that  the  writing  and  the  writing 
field  about  the  pen-point  are  hidden  by  the  writing  hand  and  the  pen- 
holder. Immediately  the  pupil  skews  the  paper,  tilts  the  head  to  the 
left,  and  grasps  the  holder  differently — all  in  order  to  bring  the  writing 
field  and  letters  being  made  into  clear  view,  and  especially  of  the  right 
or  dominant  eye. 

"The  slanted  hand^-riting  is  due  merely  to  the  fact  that  less  torsion 

^  "School  Seats,"  "Bos.  Med.  and  Surg.  Jour.,"  Oct.  5,  1899,  page  338. 

^  Distance  is  the  horizontal  distanc2  from  the  desk-edge  to  the  front  edge  of 
the  chair,  positive  when  the  chair  is  behind  the  vertical,  negative  when  they  overlap, 
nil  (Null-distanz)  when  the  edges  are  one  above  the  other. 

^  G.  M.  Gould:   "American  Medicine,"  ix,  14,  562,  1905. 


THE   WRITING    POSITION. 


107 


or  rotation  of  the  head  to  .the  right  is  rendered  necessary,  and  a  shght 
easing  is  secured  by  slanting  the  letters  to  the  right. 

"The  cure  of  the  false  position  and  of  slanted  handwriting  consists 
in:  (a)  Placing  the  paper  vertically,  and  opposite  the  right  shoulder, 
and  upon  a  desk  leaf  pitched  at  an  angle  of  30  degrees,  and  12  to  14 
inches  from  the  eye,  the  body  normally  erect  and  hygienically  posed. 


Fig.  76. — The  Hand  in  the  Writing  Posture  as  Usually  Ordered,  but  not  Prac- 
tised, Because  to  the  Writer  the  Writing   Field    is  Hidden  by  the  Thumb, 
Finger,  and  Holder.— (Cow/rf.) 
A  view  of  the  hand,  as  seen  by  the  writer,  with  the  head  displaced  in  photographing. 


(b)  Or,  by  the  use  of  angled  penholders,  leaving  the  paper  straight  in 
front  of  the  body,  (c)  The  grasping  the  old  straight  holder  between 
the  first  and  second  fingers,  or  as  the  Japanese  and  Chinese  do  their 
brushes,  from  two  to  three  inches  from  the  point,  and  the  upper  end 
held  vertically  or  somewhat  slanted  to  the  right.  This  would  require 
that  our  common  steel  pens  should  be  made  somewhat  differently." 


Chapter  VIII. 
OCCURRENCE. 

Scoliosis  is  not  wholly  a  disease  of  the  upright  position,  as  it  has 
occasionally  been  found  in  mammals,  fowls,  and  fishes.  A  case  occur- 
ring in  a  pig  has  been  carefully  studied  by  Schulthess.^  A  case  in  a 
goose  has  been  reported  by  Schmidt,^  and  it  has  been  observed  occur- 
ring spontaneously  in  a  goat.  In  such  cases  a  true  rotary  lateral  curva- 
ture has  been  found  with  a  turning  of  the  vertebral  bodies  toward  the 
convexity  of  the  lateral  curve.  Double  curves  have  been  observed. 
Experimentally  it  has  been  produced  in  dogs,  rabbits,  and  goats  by 
WuUstein,  Arnd,  and  Ribbert. 

In  the  human  spine  scoliosis  is  usually  developed  during  the  years 
of  growth.  In  its  lighter  forms  it  is  very  frequent.  Lateral  curvature 
occurs  in  all  classes  of  people,  though  certain  forms  are  more  commonly 
found  in  certain  classes  than  in  others,  e.  g.,  in  America  the  rachitic 
forms  more  frequently  occur  in  negroes  and  southern  Europeans. 

Statistics  are  lacking  as  to  the  percentage  of  scoliosis  in  the  popu- 
lation as  a  whole.  It  is  only  in  hospitals  and  institutions  that  such 
records  are  made,  and  these  cannot  be  regarded  as  indicating  the  true 
situation  because  the  clienteles  of  various  hospitals  differ  so  widely. 
As  examples  of  the  numbers  furnished  by  orthopedic  institutions  may 
be  cited  those  of  Fischer,  Behrend,  and  Schanz.  Fischer  found  353 
scolioses  among  3000  patients;  Behrend  with  the  same  number  found 
900  scolioses,  and  Schanz  in  1000  patients  found  295  cases  of  scoliosis. 
The  figures  of  Behrend  and  Schanz  show  approximately  2,3^  per  cent, 
of  scoliosis. 

Statistics  made  from  the  records  of  the  examination  of  large  num- 
bers of  school  children  are  the  only  means  of  estimating  the  percentage 
of  scoliosis  rationally,  and  they  are  especially  valuable  as  showing  the 
frequency  of  scoliosis  during  the  school  years.  The  following  table 
shows  that  scoliosis  is  found  in  from  25  to  50  per  cent,  of  the  children 
in  city  schools.     In  this,  as  in  all  the  other  tables  given,  it  must  be 

^"Zeitsch.  f.  orth.  Chir.,"  1901,  ix,  i,  page  7. 
^  "  Zeitsch.  f.  orth.  Chir.,"  1903,  xi,  2,  page  352,  with  literature. 

108 


SEX.  109 

remembered  that  the  number  of  asymmetries  recorded  depended  on  the 
standard  of  the  individual  observer,  which  varies  of  course  with  diiler- 
ent  investigators.  A  standard  which  notes  the  slightest  asymmetries 
of  the  trunk  and  the  vertebral  column  will  show  a  much  larger  percen- 
tage of  deformities  than  one  which  recognizes  only  the  easily  identified 
typical  curves.  The  figures  of  Scholder  may  be  taken  as  representa- 
tive, being  recent  statistics  taken  by  competent  observers. 

Number 
Investigator.  Examined.         Scolioses.         Per  Cent. 

Peter  Wisser 515  272  52.81 

Krug 1418  357  25.17 

Scholder 2314  571  24.7 

Brunner,  Klaussner,  and  Seydel  ....4169  ..  46.4 

Meyer 336  189  37 

Guillaume 731  218  30 

SEX. 

In  adults  it  is  generally  the  opinion  that  women  show  a  greater  num-  j 
ber  of  scolioses  than  men,  although  published  statistics  confirming  this 
fact  do  not  exist.  Records  of  the  relative  frequency  of  scoliosis  in 
boys  and  in  girls  made  in  orthopedic  institutions  where  patients  apply 
for  treatment  show  a  very  much  larger  percentage  of  scolioses  among 
girls  than  in  boys.  That  this  is  not  the  case  in  all  classes  of  the  com- 
munity was  proved  recently  by  the  examination  of  the  school  children, 
which  shows  that  young  boys  and  girls  are  almost  equally  affected 
with  scoliosis  and  that  in  some  instances  the  percentage  of  boys  is  even 
greater  than  that  of  girls.  To  explain  this  difference  we  must  either 
assume  that  boys  outgrow  scoliosis,  or  that  they  do  not  come  to  the 
institutions  for  treatment  until  the  curves  become  severe  or  until  com- 
plications arise,  while  in  girls  the  effects  of  scoliosis  upon  the  figure  are 
perceptible  much  earlier,  and  treatment  is  sought  to  remedy  curves 
which  in  boys  would  pass  unnoticed  by  the  parents.  According  to 
different  authors,  severe  forms  of  scoliosis,  usually  rachitic,  occur 
quite  as  frequently  among  boys  as  in  girls. 

The  two  tables  which  follow  are  excellent  examples  of  the  difference 
existing  between  the  records  of  orthopedic  institutions  and  the  figures 
resulting  from  the  examination  of  school  children.  The  first  table, 
from  the  records  of  institutions  where  patients  apply  for  treatment, 
shows  75  to  93  per  cent,  of  scoliosis  in  girls,  and  7  to  20  per  cent,  in 
boys.  The  second  table,  from  the  examination  of  school  children, 
shows  the  approximately  equal  occurrence  of  scoliosis  in  both  sexes. 


no  OCCURRENCE. 

Figures  from  Institutions  where  Patients  are  Treated. 

Boys.  Girls.  Boys.  Girls. 

Per  Cent.  Per  Cent.  Per  Cent.  Per  Cent. 

Etilenburg 13  87  Adams 12.8  87 

Ever 7  93  Scholder 14.8  85 

Ketch 17  83  Schanz 25  74.8 

KoUiker 20  So  Rosenthal 22  78 

Roth 8.5         91  Schulthess 14.2  85.5 

Wedberger 15.9         84  Redard 15.6  83.3 

Behrend 13.4         86 

Figures  from  School  Children. 

Boys.  Girls. 

Total  No.  No.  Scoliotic.  Per  Cent.  Total  No.  No.  Scoliotic.  Per  Cent. 

Drachmann 16,789            141              0.8  11,386  227             2 

Scholder  and  Combe.    1,290           297           23  1,024  ■  274           26.7 

Krug 695            181           26  723  163           22.5 

Wisser 292           167           57-23  223  105           47.08 

AGE. 

Scoliosis  is  an  affection  of  the  years  of  growth  in  a  large  majority  of 
cases,  but  it  is  often  extremely  difficult  'to  form  an  accurate  idea  of  the 
age  at  which  the  deformity  begins  in  individual  cases.  Scoliosis  in 
very  young  children  may  occur  from  the  first  up  to  the  fifth  year,  due 
to  rickets  and  congenital  causes.  In  general,  however,  the  inaccurate 
observations  of  parents  furnish  no  foundation  upon  which  to  base  the- 
ories or  statistics  concerning  the  time  of  the  beginning  of  the  scolioses 
observed  in  older  children. 

For  the  school  age,  the  investigations  of  Scholder  at  Lausanne  show 
a  steady  increase  in  the  percentage  of  scoliosis,  in  both  girls  and  boys, 
from  the  eighth  to  the  thirteenth  year.  This  increase  is  especially 
noticeable  from  the  eighth  to  the  eleventh  year,  and  is  probably  con- 
nected with  the  rapid  growth  of  children  during  this  period. 

Age. 


9 


13 


Boys. 

Girls. 

7.8  per  cent. 

9.7  per  cent 

6.7         " 

20.1          " 

8.3         " 

21.8 

4.2 

30.8 

7.1 

30.2          " 

6.3         " 

37-7 

In  regard  to  the  age  at  which  scoliotic  children  are  brought  for 
treatment,  Eulenburg  found  over  50  per  cent,  of  all  cases  between  seven 
and  ten  years  old,  and  but  10  per  cent,  between  the  ages  of  ten  and 
fourteen  years. 

The  clinical  material  collected  by  the  Institute  of  Liining  and 
Schulthess  at  Zurich  has  been  used  by  Sutter  and  Miiller  in  preparing 
curves  of  the  frequency  of  scoliosis  at  different  ages.     Miiller  finds  the 


FREQUENCY   OF   DIFFERENT    FORMS.  Ill 

greater  number  of  cases  in  the  fourteenth  year.  The  number  increases 
gradually  from  the  eighth  to  the  fourteenth  year,  and  decreases  rapidly 
from  the  fourteenth  to  the  seventeenth  year.  Sutter  found  that  the 
number  of  boys  brought  for  treatment  reached  the  maximum  in  the 
ninth,  thirteenth,  and  fourteenth  years.  The  number  of  cases  under 
treatment  at  fourteen  years  of  age  is  double  that  for  nine  years,  and 
shows  not  only  an  increase  in  frequency  of  scoliosis,  but  an  increase  of 
deformity  in  curves  already  existing. 

Reviewing  the  occurrence  and  frequency  of  scoliosis  the  following 
statements  can  be  made:  (i)  Scoliosis  occurs  in  all  classes  of  people. 
(2)  There  are  no  statistics  concerning  the  proportion  of  scoliosis  among 
adults.  (3)  Children  of  both  sexes  show  from  25  to  50  per  cent,  of 
scoliosis  during  the  school  years,  with  the  best  authenticated  average 
at  about  26  per  cent.  (4)  With  regard  to  sex — (a)  in  adults  women 
are  generally  supposed  to  be  affected  with  scoliosis  more  often  than 
men ;  (b)  of  children  at  school,  boys  and  girls  are  about  equally  affected ; 
(c)  of  children  coming  for  treatment,  the  girls  very  largely  outnumber 
the  boys.  (5)  Scoliosis  has  been  observed  in  children  from  the  first  year. 
The  age  at  which  the  greater  number  of  cases  are  recorded  for  treatment 
is  given  by  Eulenburg  as  from  seven  to  ten,  and  by  Schulthess  as 
fourteen  years. 

RELATIVE  FREQUENCY  OF  THE  DIFFERENT  FORMS  OF  SCOLIOSIS. 

Statements  concerning  the  frequency  of  the  simple  forms  of  scolio- 
sis are  of  very  recent  origin.  All  statistics  agree,  howxver,  in  showing 
that  for  all  forms  there  aire  more  scolioses  convex  to  the  left  than  to  the 
right.  There  is  less  unanimity  as  to  which  of  the  single  forms  is  the 
most  frequent.  Lorenz  states  that  left  lumbar  scoliosis  is  the  most 
numerous.  KoUiker,  from  the  examination  of  721  cases,  finds  the  sim- 
ple dorsal  scoliosis  the  most  frequent.  By  considering  the  tables  of 
other  investigators  Schulthess  found  the  compound  right  dorsal  scolio- 
sis the  most  frequent  form,  followed  in  order  by  the  simple  dorso- 
lumbar  curves,  total  scoliosis,  and  lumbar  scoliosis.  The  cervicodorsal 
form  was  the  least  frequent. 

Among  the  571  school  children  with  lateral  curvature  out  of  2134 
children  examined  by  Scholder  at  Lausanne,  401,  or  60.3  per  cent., 
showed  curves  convex  to  the  left,  121,  or  21. i  per  cent.,  curves  convex  to 
the  right,  and  49,  or  8.6  per  cent.,  compound  curves.  The  table  compiled 
by  Scholder  shows  the  percentage  of  curves  as  to  their  form  and  con- 
vexity.    The  total  cvirve  is  the  most  frequent  form  in  school  children, 


112  OCCURRENCE. 

and  is  followed  by  the  left  and  right  lumbar  curves  and  by  left  dorsal 
scoliosis. 

Left  Convex.     Right  Convex.  Total. 

Total  scoliosis 48.1  per  cent.     7.8  per  cent.  56     per  cent. 

Dorsal  scoliosis 8.4         "  4.3         "  12.7         " 

Lumbar  scoliosis 11.8         "  8.5         "  20.3         " 

Combined  scoliosis 8.5  per  cent.  8.5'        " 

Almost  the  only  records  that  have  been  studied  and  tabulated  for 
definite  study  are  those  of  the  Institute  of  Liining  and  Schulthess,  and 
it  is  from  these  investigations  that  much  of  the  following  material  is 
drawn. 

Age. — At  eight  years  the  left  scolioses  form  64  per  cent,  and  the 
right  scolioses  33  per  cent,  of  the  total  number  of  curves.  In  the  four- 
teenth year  the  number  of  curves  convex  to  the  left  and  right  is  about 
equal.  The  number  of  compensating  curves  increases  from  27  per 
cent,  in  the  eighth  year  to  45  per  cent,  in  the  seventeenth  year. 

Position  of  Apex  of  Deviation. — To  ascertain  the  location  of  the 
point  of  deviation  Durrer  has  constructed  a  set  of  curves  which  show 
that  for  the  .left  convex  scolioses  the  maximum  deviation  is  at  the  dorso- 
lumbar  junction,  and  for  the  right  convex  curves  the  apices  are  found 
in  the  region  of  the  seventh  dorsal  vertebra,  which  showed  a  much 
greater  deviation  than  the  adjacent  vertebrae,  while  in  the  left  convex 
curves  the  deviation  is  more  evenly  distributed  over  the  length  of  the 
spine. 

Schulthess  finds  four  principal  apices  of  deviation  for  single  and  com- 
pound forms  of  scoliosis:  (i)  The  upper  dorsal  region  to  the  right; 
(2)  the  dorsolumbar  junction  to  the  left;  (3)  the  upper  dorsal  and  lower 
cervical  regions  to  the  left;    (4)  the  lower  lumbar  region  to  the  right. 

In  the  eighth  year  the  maximum  deviation  of  the  right  dorsal  curves 
is  in  the  region  of  the  sixth  to  the  eighth  dorsal  vertebrae,  and  is  still 
found  there  in  the  seventeenth  year.  The  apex  of  the  left  convex 
curves  in  the  eighth,  ninth,  and  tenth  years  is  at  the  ninth  or  tenth  dor- 
sal vertebra;  between  the  ages  of  eleven  and  thirteen  it  is  found  at  the 
twelfth  dorsal  vertebra,  and  descends  to  the  first  or  second  lumbar 
vertebra  between  the  ages  of  fifteen  and  eighteen  years. 


Chapter  IX. 
DIAGNOSIS. 

Scoliosis  is  an  affection  in  most  cases  appearing  before  the  tenth 
year;  it  is  not  a  disease  of  the  spine  but  the  result  of  mechanical 
forces  acting  upon  a  spine  which  for  some  reason  is  abnormally  formed 
or  possesses  less  than  normal  resistance.  It  is  not  accompanied  by  any 
degree  of  pain  and  none  in  its  earlier  stages.  Stiffness,  if  it  is  present, 
is  an  accompaniment  of  late  cases  and  the  result  of  long-continued  struct- 
ural changes.  The  curvature  of  the  spine  is  self-evident  if  one  hangs 
a  plumb-line  in  the  middle  of  the  back,  and  scoliosis  can  be  said  either 
to  be  present  or  absent  in  any  given  case.  Of  course,  absolute  sym- 
metry does  not  exist,  but  a  perceptible  variation  of  the  line  of  spinous 
processes  from  a  straight  line  situated  in  the  median  anteroposterior 
(sagittal)  plane  of  the  body  constitutes  scoliosis. 

It  is  important,  first,  to  recognize  lateral  curvature  when  it  exists; 
second,  it  is  desirable  to  identify  the  cause  of  the  affection  if  possible; 
and,  third,  it  is  essential  to  discriminate  from  scoliosis  other  affections 
resembling  it,  of  which  it  is  only  a  symptom. 

First,  the  recognition  of  scoliosis  has  been  sufficiently  discussed  in 
speaking  of  the  method  of  examination  (see  chapter  on  Examination 
and  Record). 

Second,  the  differentiation  of  the  varieties  of  scoliosis  is  to  be  made 
by  the  recognition  of  special  characteristics  in  each  case  (see  chapter  on 
Description  and  Symptoms) . 

Scoliosis  of  Congenital  Origin. — The  A;-ray  is  of  importance  in 
making  plain  the  character  of  the  bony  deformity.  In  the  class  of 
cases  where  a  comparatively  slight  congenital  anomaly  is  present  the 
use  of  the  .T-ray  is  essential  to  establish  the  congenital  origin  of  the  case. 
Where  due  to  defects  in  the  thorax  or  scapula,  the  scoliosis  is  located 
in  the  upper  part  of  the  column,  is  s'evere  and  exists  in  early  life. 
The  defects  in  the  chest  or  thorax  are  usually  self-evident. 

Acquired  Scoliosis. — In  acquired  scoliosis  the  existence  of  torti- 
collis, pelvic  asymmetry,  and  impaired  vision  or  hearing  are  competent 
causes  of  the  deformity  and  should  have  been  identified  in  the  examina- 
tion. The  existence  of  any  one  makes  it  likely  that  the  scoliosis  is  due 
8  113 


114  DIAGNOSIS. 

to  that  as  a  cause.  The  discovery  that  one  leg  is  shorter  than  the  other 
does  not  establish  that  as  the  necessary  cause  of  the  scoliosis  for  the 
reasons  mentioned,  although  it  is  a  competent  cause. 

Rickets  is  one  of  the  most  frequent  causes  of  severe  scoliosis.  It 
occurs  early  and,  as  a  rule,  this  is  a  severe  and  intractable  form.  ]Most 
often  the  curve  is  lumbar  or  dorsolumbar,  a  compound  curve  with 
marked  deformity  of  the  thorax,  or  cervicodorsal.  Asymmetry  of  the 
head  is  said  by  Schulthess  to  be  a  frequent  accompaniment.  The  curves 
are  generally  rather  sharp,  thoracic  deformity  is  frequent,  and  rotation 
appearances  conspicuous.  The  existence  of  signs  of  former  rickets  is 
presumptive  evidence  of  this  form  of  deformity;  these  are  enlarged 
epiphyses,  a  rosary  or  beading  of  the  anterior  ends  of  the  ribs,  a  square 
prow-shaped  forehead,  and  the  curvature  of  the  long  bones. 

Osteomalacia  as  a  cause  of  scoliosis  is  made  evident  by  the  existence 
of  the  disease  elsewhere. 

Diseases  of  the  joints,  of  the  arms,  or  legs  is  easily  distinguished  and 
mention  need  only  be  made  that  this  is  a  competent  cause  of  scoliosis. 

Infantile  paralysis  is  a  motor  paralysis  of  certain  groups  of  muscles 
or  of  a  whole  limb.  It  is  manifested  by  loss  of  power  in  the  affected 
muscles,  by  loss  or  diminution  of  reflexes,  by  coldness  and  muscular 
atrophy,  and  the  reaction  of  degeneration  in  the  muscles  to  electricity. 
The  resulting  curves  are  most  often  low  in  the  spine,  are  characterized 
by  great  deformity  and  shortening  of  the  trunk,  and  are  not  easily  mis- 
taken for  other  forms  of  scoliosis.  The  frequent  association  of  scolio- 
sis with  infantile  paralysis  of  one  or  both  legs  from  some  slight  involve- 
ment of  the  back  muscles  makes  it  imperative  to  examine  the  back  in 
every  case  of  infantile  paralysis. 

Nervous  disease  of  other  forms  may  be  accompanied  by  scoliosis, 
but  in  these  it  is  generally  of  secondary. importance  and  only  of  slight 
or  moderate  degree  as  a  rule. 

Empyema  and  pleurisy  are  recognized  as  the  causes  of  a  severe 
form  of  scoliosis,  especially  when  a  resection  of  the  rib  has  been  per- 
formed in  empyema.  The  curve  is  always  convex  toward  the  unaffected 
side  of  the  chest  and  is  dorsal  or  dorsolumbar.  It  is  identified  by  the 
scar  on  the  chest  or  the  auscultation  signs  in  the  thorax  and  the  history 
of  the  case.  Any  other  scar  of  sufficient  size  is  competent  to  produce 
the  same  result. 

Organic  heart  disease  is  in  some  cases  accompanied  by  and  is  pre- 
sumably the  cause  of  a  scoliosis.  As  the  examination  of  the  heart 
should  form  a  routine  part  of  all  examinations  for  scoliosis,  this  should 
be  easilv  detected. 


SCOLIOSIS    AS   A   SYMPTOM.  II 5 

Cases  of  scoliosis  which  do  not  fall  into  one  of  the  above  divisions 
may  be  classed  as  Jiahit  or  school  scolioses,  which  is  an  admission  that 
we  are  ignorant  of  the  real  cause  in  the  individual  case. 

Pathological  Conditions  Accompanied  by  Lateral  Curvature  as  a 
Symptom. — Cases  of  lateral  curvature  accompanied  by  pain,  especially 
if  this  is  exaggerated  by  motion,  should  not  be  given  exercises,  but  kept 
under  careful  observation  until  a  perfectly  definite  diagnosis  has  been 
made.  The  same  applies  to  slight  curves  accompanied  by  stiffness  of 
the  spine.     DouJotful  cases  may  be  cleared  up  by  the  use  of  the  ,T-ray. 

The^cmust  be  carefully  separated  from  true  scoliosis.  The  chief 
one  of  tnese  is  Pott's  disease,  or  tuberculosis  of  the  spine.  The  symp- 
toms of  this  affection  are  stiffness  of  gait  and  loss  of  mobility  in  the 
spine,  pain  on  motion  or  jar  and  spontaneous  pain  in  the  chest  and  abdo- 
men, elevation  of  temperature,  and  impairment  of  the  general  condi- 
tion. As  the  disease  progresses  a  sharp  prominence  backward  of  the 
spinous  processes  occurs  at  some  part  of  the  spine.  Abscesses  in  the 
neck,  the  loin,  and  the  iliac  region  occur  in  severe  cases.  Lateral  devia- 
tion of  the  spine  occurs  in  the  acute  stage  of  practically  all  cases,  but  it 
is  a  leaning  of  the  body  to  one  side  rather  than  a  true  gradual  curve; 
there  is  no  rotation  of  note,  and  the  lateral  deviation  is  an  index  of  the 
severity  of  the  disease  disappearing  after  a  period  of  recumbency  in  bed 
and  being  controlled  by  efficient  treatment.  The  danger  of  mistaking 
Pott's  disease  for  scoliosis  lies  in  the  early  cases  before  the  knuckle,  or 
backward  deformity,  has  occurred. 

A  form  of  lateral  deviation  of  the  spine  accompanies  arthritis  defor- 
mans, which  is  also  known  under  the  names  of  osteoarthritis  of  the 
spine,  spondylitis  deformans,  ankylosis  of  the  spine,  spondylose  rhizo- 
melique,  Bechterew's  disease,  Steifigkeit  der  Wirbelsaiile,  etc.  This 
is  essentially  an  affection  of  adult  life,  but  not  unknown  in  children. 
The  spine  is  stiff  and  painful,  the  lumbar  convexity  is  diminished  or 
lost,  and  the  curve  a  gradual  one  with  slight  or  no  rotation.  The  lat- 
eral curve  accompanying  tumors  of  the  spine,  dislocation  of  the  verte- 
bra?, etc.,  would  hardly  be  mistaken  for  real  scoliosis,  the  usual  signs 
of  those  affections  being  present. 


Chapter  X. 
PROGNOSIS. 

WITHOUT  TREATMENT. 

Total  curves  may  remain  as  such  through  life,  probably  increasing 
somewhat;  they  may  change  to  structural  curves,  or  they  may  be  cured 
by  proper  treatment,  but  they  are  not  likely  to  disappear  spontaneously. 
So  long  as  they  remain  purely  functional  curves,  as  defined  above, 
they  will  probably  not  influence  the  general  health  unfavorabl)^  or  pro- 
duce any  unpleasant  result  further  than  slight  asymmetry.  In  neuras- 
thenic women  they  are  frequently  accompanied  by  backache. 

Structural  curves,  whether  simple  or  compound,  in  young  children 
should  be  regarded  as  serious,  as  almost  sure  to  increase,  and  perhaps 
to  increase  rapidly.  They  will  surely  lead  to  some  deformity,  and  per- 
haps to  grave  deformity.  They  are  likely  to  affect  the  general  health 
and  to  shorten  life  by  inducing  phthisis  and  ill  health.  Adults  with 
severe  scoliosis  are,  as  a  rule,  less  vigorous  than  normal. 

Structural  curves  in  older  children  and  adolescents  which  have  not 
progressed  rapidly  through  childhood  are  after  puberty  likely  to  increase 
but  slowly  until  late  middle  life,  when  the  atrophy  of  the  intervertebral 
discs  is  likely  to  make  them  more  evident  and  troublesome.  Severe 
structural  scoliosis  at  any  period  of  life  is  to  be  regarded  as  likely  to 
shorten  the  patient's  life  and  to  induce  ill  health.  The  rapid  increase 
of  a  postural  or  structural  curve  is  a  threatening  symptom  demanding 
attention. 

WITH  TREATMENT. 

Total  scoliosis  should  be  entirely  and  permanently  cured  by  ad- 
equate treatment. 

Structural  scoliosis  in  young  children  when  of  moderate  degree 
should  be  practically  cured  by  adequate  and  long-continued  treatment, 
but  only  by  that.  If  severe,  it  should  be  much  improved  by  the  same 
means,  the  prognosis  in  both  classes  being  better  in  children  with  a 
long  period  of  growth  ahead  than  in  adolescents. 

Structural  curves  in  older  children  and  adolescents  when  of  moder- 
ate degree  should  be  greatly  improved  by  adequate  and  long-continued 

ii6 


PROGNOSIS    WITH   TREATMENT.  II7 

treatment,  but  cannot  be  wholly  cured.  Severe  structural  scoliosis 
under  these  conditions  can  be  markedly  improved. 

WTien  growth  has  been  reached,  only  improvement  and  not  com- 
plete cure  is  to  be  hoped  for  from  treatment  in  scoliosis  of  any  form. 
In  adults  with  severe  scoliosis  the  general  condition  of  the  patient  may 
be  greatly  improved  by  an  improved  position  of  the  spine.  In  late 
adult  life  support  of  the  spine  in  the  best  obtainable  position  is  the  only 
outlook  from  treatment,  again  often  attended  by  improvement  of  the 
general  health. 

Scoliosis  due  to  severe  congenital  defects  of  the  vertebrae,  scapulae,  or 
thorax,  to  infantile  paralysis,  or  to  empyema  cannot  be  cured,  but  can 
be  improved.  Rickets  contributes  a  class  of  cases  on  the  whole  resis- 
tant to  treatment,  and  in  severer  cases,  even  in  young  children,  a  com- 
plete cure  is  not  obtainable.  The  existence  of  organic  heart  disease 
or  phthisis  makes  the  prospect  of  obtaining  much  improvement  from 
treatment  unfavorable. 


Chapter  XI, 

TREATMENT. 

The  treatment  of  scoliosis  can  be  most  clearly  considered  if  one 
separates  for  purposes  of  discussion  the  two  types  of  cases  already 
described  (page  49) — (i)  the  postural  or  functional,  and  (2)  the  organic 
or  structural.  That  such  a  distinction  is  not  always  sharply  to  be  made, 
that  transition  cases  are  to  be  seen,  and  that  many  therapeutic  measures 
are  common  to  both  classes  of  cases,  applies  here  as  in  most  other  de- 
partments of  medicine  and  surgery  where  functional  and  organic  con- 
ditions are  separated. 


THE  TREATMENT  OF  POSTURAL  SCOLIOSIS  (FUNC- 
TIONAL SCOLIOSIS). 

Regarding  the  condition  as  an  habitual  inability  to  stand  correctly, 
as  a  postural  malposition  without  marked  structural  change,  it  is  evi- 
dent that  the  treatment  should  consist  in  the  substitution  of  a  correct 
attitude  for  the  faulty  one.  This  is  obviously  to  be  preceded  by  elim- 
inating conditions  unfavorable  to  the  maintenance  of  a  correct  up- 
right position  and  by  tonicity.  The  conditions  requiring  investigation 
and  possible  correction  are — (i)  seats  and  desks  at  school;  (2)  the 
manner  of  clothing  the  child;  (3)  the  condition  of  the  eyes  and  ears; 
(4)  the  existence  of  a  short  leg;  (5)  overwork  or  too  long  hours,  lead- 
ing to  persistent  fatigue.  These  matters  are  also  of  importance  in 
structural  lateral  curvature.  Having  placed  the  patient  under  the  most 
favorable  conditions  obtainable  and  having  corrected  the  defects  above 
mentioned,  the  patient  should  work  on  the  exercises  to  be  described 
for  from  half  an  hour  to  two  hours  a  day  for  a  period  of  some  weeks. 
The  exercises  should  not  be  pushed  beyond  the  limit  of  fatigue,  and 
after  the  active  period  has  ceased  the  child  should  do  home  gymnas- 
tics and  be  kept  under  supervision  for  at  least  a  year.  The  length 
of  treatment,  the  period  of  the  exercises,  and  the  extent  to  which  they 
can  be  pushed  will  depend  on  the  vigor  of  the  child,  as  half-way  mea- 
sures are  not  likely  to  be  successful  and  exercises  clone  at  home  under 
the  supervision  of  careless  parents  are  less  efficient  than  those  given  by 

118 


STRUCTURAL   SCOLIOSIS.  IIQ 

persons  trained  in  the  art  of  gymnastics.  The  treatment  lies  within 
the  range  of  any  good  teacher  of  gymnastics  who  will  carry  out  the 
instructions  of  the  surgeon.  The  causes  of  failure  are  to  be  found 
in  the  fact  that  such  children  are  generally  in  poor  muscular  condition 
and  are  often  overworked  at  school  or  under  unfavorable  conditions 
at  home,  or  that  the  exercises  are  given  too  seldom  and  are  not  suffi- 
ciently vigorous. 

If  flexibility  to  one  side  is  limited,  i.  e.,  if  the  child  can  bend  further 
to  the  right  than  to  the  left  in  a  left  total  curve,  the  flexibility  of  the 
spine  must  be  made  equal,  preferably  by  means  of  passive  lateral  stretch- 
ing in  the  apparatus,  described  on  page  146,  or  by  means  of  gymnas- 
tic exercises.  Haxing  restored  the  flexibility  of  the  spine  by  this  means 
or  if  flexibility  to  the  two  sides  is  alike,  a  treatment  differing  but  little 
from  the  "setting-up  drill"  of  the  army  recruit  is  to  be  instituted.  Ex- 
ercises suitable  for  the  treatment  of  postural  cases  will  be  described 
in  connection  with  the  gymnastic  treatment  of  structural  scoliosis 
(page  127). 


TREATMENT  OF  STRUCTURAL  SCOLIOSIS  (ORGANIC 
SCOLIOSIS,  HABITUAL  SCOLIOSIS,  FIXED  SCOLIOSIS). 

The  problem  to  be  met  in  the  treatment  of  lateral  curvature  with 
fixed  bony  changes  is  a  perfectly  definite  one.  A  clear  understanding 
of  the  obstacles  to  be  met  and  of  the  means  at  our  disposal  for  meet- 
ing them  is  essential  to  successful  treatment. 

The  spinal  column  having  curved  to  one  side  has  in  the  course  of 
years  become  fixed  in  the  deformed  position.  In  addition  to  the  side 
curve,  a  rotation  or  twist  in  the  length  of  the  column  has  occurred  at 
the  seat  of  the  main  and  compensatory  lateral  curves,  particularly 
evident  in  the  thorax.  As  the  result  of  the  maintenance  of  the  vicious 
position  over  a  long  time,  covering  part  of  the  period  of  growth,  changes 
in  bones,  muscles,  ligaments,  and  intervertebral  discs  have  occurred. 
The  individual  vertebne  have  become  compressed  on  one  side  or  twisted 
by  the  rotation.  The  ligaments  and  muscles  have  become  adap- 
tively  shortened  on  one  side  and  stretched  on  the  other,  and  the  inter- 
vertebral discs  to  a  greater  or  less  extent  have  become  compressed  on 
one  side.  The  region  of  the  vertebral  column  involved  by  the  curve 
has  lost  its  normal  mobility  and  is  partly  or  wholly  stiff.  There  are 
secondary  changes  in  the  thorax  and  abdomen  and  in  the  contained 
organs. 

It  is  obvious  that  in  the  upright  position  gravity  works  to  increase 


I20  TREATMENT. 

the  deformity  by  exerting  pressure  upon  the  concavity  of  the  curves 
already  atrophied  by  an  abnormal  weight  bearing.  Of  the  twenty- 
four  hours  in  each  day  only  some  eight  or  ten  at  most  are  spent  in  recum- 
bency. During  the  remaining  fourteen  or  sixteen  hours  the  vertical 
position  is  assumed  and  gravity  is  at  work. 

The  treatment  of  structural  lateral  curvature  presents,  therefore, 
a  much  more  serious  and  much  less  encouraging  problem  than  the 
treatment  of  postural  cases,  and  measures  must  be  vigorous,  adequate, 
and  surgically  sound  to  produce  a  permanently  satisfactory  result. 

The  causes  of  failure  lie  in  the  unwillingness  of  the  parents  or  the/ 
patient  to  submit  to  sufi&ciently  long-continued  and  effecti\-e  treatment 
to  remedy  a  condition  which,  on  the  slightest  consideration,  can  be 
seen  to  be  one  which  is  necessarily  difi&cult  and  resistant. 

The  surgical  treatment  of  structural  lateral  curvature  must  obviously 
consist  of  two  divisions:  First,  to  loosen  up  the  stiffened  parts  of 
the  spine  to  make  an  improved  position  possible,  and,  second,  to  hold 
the  improved  position  when  it  has  been  rendered  possible.  These 
two  elements  are  not  sufficiently  separated  as  a  rule  in  treatment;  they 
frequently  go  hand  in  hand  and  treatment  must  often  be  simultaneous 
for  both,  but  it  adds  very  much  in  a  clear  formulation  of  treatment 
to  keep  the  two  things  perfectly  separate. 

The  treatment  of  structural  lateral  curvature  will  be  described 
under  the  following  headings:  Gymnastics  with  Apparatus;  Gymnastics 
without  Apparatus;  Passive  Stretching;  Forcible  Correction;  Braces 
and  Corsets;   Operative  Treatment. 

GYMNASTICS. 

Gymnastics  have  a  two-fold  object — first,  .to  loosen  up  the  curved 
portion  of  the  spine  to  make  an  improved  position  possible,  and,  second, 
to  aid  in  retaining  the  improved  position  by  strengthening  certain  groups 
of  muscles.  Most  exercises  tend  in  a  measure  to  accomplish  both  of 
these,  so  that  a  division  into  mobilizing  and  retentive  exercises  is  not 
possible,  and  one  can  only  point  out  that  a  certain  exercise  is  especially 
valuable  for  one  or  the  other  purpose. 

It  is  essential  to  define  and  limit  what  place  gymnastics  should 
occupy  in  the  treatment  of  structural  scoliosis.  It  is  obviously  unrea- 
sonable to  expect  free  standing  gymnastic  exercises  to  straighten  marked 
or  severe  curves  or  to  change  the  shape  of  distorted  bones.  But  after 
the  greatest  possible  improvement  has  been  secured  in  such  curves  by 
more  efiicient  measures  (passive  stretching  and  forcible  correction) 
one  must  look  to  gymnastics  to  develop  the  muscles  which  will  hold 


GYMNASTIC   TREATMENT. 


the  improved  position  and  make  the  gain  permanent  after  the  correc- 
tive jacket  has  been  gradually  discontinued.  In  marked  and  severe 
structural  scoliosis,  therefore,  gymnastic  treatment  finds  its  best  use 
as  supplementary  to  forcible  correction. 

The  purely  gymnastic  treatment  of  severe  structural  scoliosis  is 
to-day  being  largely  pursued  by 
two  classes  of  persons.  First, 
by  irresponsible  masseurs  and 
medical  gymnasts  who  hold  as 
a  tradition  that  gymnastic  ex- 
ercises are  curative  or  at  least 
helpful  in  scoliosis,  and,  second, 


liLiSU 


Fig.  77. — Patient  with   Left  Dor- 
sal Curve  in  1900. 


Fig.   78. — Same  Patient  in  1905  af- 
ter  Five  Years  of  Gy.mnastic 

Treatment. 


by  competent  surgeons  who  do  not  believe  in  corsets  or  supports.* 
The  former  class  serves  only  to  bring  the  legitimate  use  of  gym- 
nastics for  scoliosis  into  disrepute;  the  latter  class  use  the  gym- 
nastics understandingly,  and,  on  the  whole,  take  a  pessimistic  view  of 
the  results  to  be  obtained  in  severe  scoliosis.     Moreover,  it  is  a  mistake 

'  Teschner:    "N.  Y.  Med.  Rec,"  Dec.  6,  1903;  Erich:    "N.  Y.  Med.  Jour.," 
Oct.   7,   1S99. 


122  TREATMENT. 

to  make  a  spine  more  flexible  unless  one  is  prepared  to  hold  the  spine 
in  the  improved  position  by  a  corset  or  brace  or  by  muscular  develop- 
ment, because  if  flexibility  is  increased,  the  spine  will  sink  further 
into  the  bad  position  by  virtue  of  its  increased  mobility  unless  some 
means  is  provided  to  prevent  this.  In  mild  structural  scoliosis 
efiicient  gymnastics  may  constitute  the  sole  treatment,  and  may  be 
continued  as  the  sole  treatment  so  long  as  the  improvement  from  one 


Fig.  79. — Trunk   Bending   Appa- 
ratus.— (Sc/iuUhess.) 


Fig.   So.— Shoulder   Pushing   Apparatus.- 
(SchuUliess.') 


e.xercise  period  persists  until  the  next  one.  If  such  improvement  is 
not  held  between  exercises  it  must  be  assumed — (i)  that  the  exercises 
are  not  good  ones;  (2)  that  they  are  not  properly  carried  out;  (3)  that 
the  amount  of  treatment  is  insufficient,  or  (4)  that  the  case  is  too 
severe  for  purely  gymnastic  treatment.  Progressive  improvement  must 
be  assumed  as  the  criterion  of  efficient  gymnastic  treatment,  and  it 
must  be  recognized  that,  on  the  whole,  gymnastic  treatment  by  itself  is 


GYMNASTICS   IN   APPARATUS. 


123 


not  satisfactory  in  scoliosis  -characterized  by  any  marked  degree  of  bony 
deformity. 

The  treatment  by  gymnastics  alone  may  be  supplemented  (a)  by 
the  use  of  jackets,  braces,  or  corsets,  or  (h)  by  the  use  of  intermittent 
passive  stretching,  or  (c)  by  both.  If  the  case  is  too  severe  for  gym- 
nastics, (d)  forcible  correction  followed  by  gymnastics  and  corsets  is 
the  proper  treatment.     The  use  (e)  of  braces  and  corsets  alone  is  not 


Fig.  81. — HiP-PENDULCM  and  Shoulder-raising  Apparatus. — {Schulthess.) 


to  be  considered  a  treatment  for  lateral  curvature.  Gymnastic  treat- 
ment may  be  given  with  or  without  apparatus. 

Gymnastics  Given  in  Apparatus. — By  means  of  apparatus  gym- 
nastic exercises  can  be  very  much  more  correctly  localized,  and  the 
work  of  loosening  the  spine  and  of  strengthening  the  desired  muscles 
can  go  hand  in  hand.  This  method,  which  is  in  general  use  in  Europe, 
has  never  found  a  foothold  in  this  country  on  account  of  the  compli- 
cated and  expensive  apparatus. 

The  system  of  apparatus  devised  by  Schulthess  and  its  modifica- 


124  TREATMENT. 

tions  and  the  apparatus  of  Zander  are  the  best  examples  of  the  kind. 
The  aim  of  this  method  of  treatment,  as  stated  by  Schulthess,  is  "to 
correct,  and  in  the  corrected  position  to  allow  exercises  to  be  done,  or 
through  the  movements  carried  out  in  the  apparatus  to  shape  o^•er  the 
body  from  the  pathological  to  the  corrected  form."  The  various  forms 
of  apparatus  are  as  follows:  (i)  For  side  bending  with  the  pelvis  fixed; 
(2)  for  side  bending  with  the  shoulders  and  pelvis  fixed;  (3)  for 
forward  and  backward  bending;  (4)  for  trunk  rotation;  (5)  for 
active  transverse  pushing  of  the  shoulder-girdle;  (6)  for  active  rais- 
ing of  the  shoulder ;  (7)  for  active  movement  of  the  thorax  with  shoul- 
ders and  pelvis  fixed.  In  some  of  these  the  pendulum  principle  is 
used. 

The  precision  of  the  apparatus,  its  adaptation  to  anatomical  needs, 
and  the  principle  of  securing  correction  and  the  development  of  desired 
muscles  at  the  same  time  make  the  system  sound  and  efficient.  It  is 
described  in  detail  in  the  reference,^  and  is  not  dwelt  on  here  as  it  is  a 
treatment  not  often  available  in  America  (Figs.  79,  80,  81). 

Gymnastic  Exercises  Given  without  Apparatus. — This  method 
of  treatment  is  the  one  in  most  general  use  in  America.  It  is  open  to 
the  objection  that  the  force  exerted  is  not  sufficiently  localized,  but  is 
distributed  over  the  spine. 

Fixation  oj  Pelvis. — It  is  essential  that  the  pelvis  should  be  fixed 
diiring  such  exercises,  as  otherwise  the  pelvis  is  displaced  and  the  move- 
ment becomes  a  general  and  not  a  local  one.  A  simple  wooden  appa- 
ratus may  be  constructed  which  holds  the  pelvis  and  does  away  with 
the  necessity  of  holding  the  hips  of  the  patient  between  the  knees> 
which  must  otherwise  be  done.  This  saves  labor  on  the  part  of  the 
person  giving  the  exercises,  and  permits  a  closer  supervision  of  the  back 
than  is  possible  when  part  of  the  attention  must  be  fixed  on  holding 
the  patient  firmly. 

The  apparatus,  which  was  suggested  by  that  of  Bade,"  consists  of  a 
wooden  clamp  made  by  two  flat  boards  set  at  right  angles  to  a  hori- 
zontal board  on  which  they  slide  to  hold  the  sides  of  a  pelvis  of  any  width. 
The  whole  apparatus  moves  up  and  down  on  an  upright  fastened  to 
a  large  round  floor  platform  and  may  be  inclined  at  any  angle  to  the 
horizontal  plane.  The  patient  is  secured  in  place  by  sliding  in  and 
fastening  the  lateral  clamps  at  the  sides  of  the  pelvis,  and  by  securing 
the  front  of  the  pelvis  by  a  broad  leather  strap  passing  from  one  arm 

^  Schulthess:  Joachimsthal's  "Hdbch.  der  orth.  Chir.,"  Lief  v,  page  1104. 
^  "Zeitsch.  f.  orth.  Chir.,"  xii,  4,  799. 


GYMNASTIC   TREATMENT. 


125 


to  the  other.     The  floor  platform  is  so  large  that  the  apparatus  cannot 
upset  (Fig.  84). 

General  Routine  and  Precautions. — It  is  desirable  that  the  back  should 
be  exposed  during  the  exercises  in  order  to  note  the  effect  of  each  one. 
For  this  purpose  the  patient  should  wear  during  exercises  a  loose  cotton 


Fig.  82.— Composite  Photograph  (Two 
Exposures  on  the  Same  Plate) 
Showing  the  Model  Standing 
Erect  and  Bending  to  the  Right 
without  Fixation  of  the  Pelvis. 
The  Movement  is  a  General  One. 


Fig.  S3.— Composite  Photograph  of 
THE  Model  Standing  Erect  and 
Bending  to  the  Right  with  the 
Pelvis  Fixed.  The  Movement  is 
Limited  to  the  Spine. 


dressing  jacket,  fastened  around  the  neck  and  opening  in  the  back. 
This  protects  the  front  of  the  body  but  permits  inspection  of  the  spine. 
Such  exercises  should  be  simple  and  corrective  in  the  strict  sense; 
that  is  to  say,  an  exercise  which  is  of  use  should  be  seen  to  straighten 
the  spine  visibly.     Complicated   exercises  are  dangerous  and  unsur- 


126 


TREATMENT. 


gical.  Work  to  obtain  results  must  be  given  by  a  competent  gym- 
nast for  a  period  of  from  one  to  three  hours  a  day,  according  to  the 
vigor  of  the  patient,  and  must  be  continued  under  personal  supervision 
for  a  period  of  some  weeks  or  months  to  obtain  satisfactory  results. 
After  this  exercises  at  home  can  be  substituted  for  part  of  the  personal 
work. 

As  a  preliminary  of  gymnastic  work  the  heart  of  the  patient  should 
have  been,  of  course,  examined,  and  the  weight  should  be  taken  each 
week.     Persistent  loss  of  weight  is  an  indication  for  moderating  or 


Fig.  84. — Apparatus  for  Fi.xing  the  Pelvis  During  Gymnastic  Exercises. 


discontinuing  temporarily  the  exercises,  providing  that  the  patient  is 
not  being  overworked  at  school,  in  which  case  the  school  conditions 
should  first  be  remedied.  During  menstruation  gymnastic  exercises 
should  be  suspended.  Persistent  fatigue,  anemia,  loss  of  appetite, 
nervousness,  and  frequent  or  profuse  menstruation  should  cause  a  care- 
ful investigation  of  the  patient's  environment,  as  they  may  arise  from 
excess  of  gymnastic  work. 

The  following  list  of  gymnastic  exercises,  selected  from  a  large 
number,  may  be  regarded  as  representative  of  the  kind  of  gymnastics 
likelv  to  be  of  use  within  the  limits  mentioned  above.     They  will  first 


SYMMETRICAL    EXERCISES.  1 27 

be  described  indi\idually  and  then  analyzed,  and  their  apfiHcation  to 
different  conditions  will  be  indicated. 

The  selection  of  exercises  must  depend  on  the  requirements  of  each 
case,  and  so  far  as  possible  the  especial  value  of  each  exercise  has  been 
indicated.  Simple  developmental  exercises  have  not  been  included 
here,  as  a  description  of  them  can  be  found  in  books  on  gymnastics. 

In  the  explanations  to  be  given  in  connection  with  each  exercise 
the  general  mechanical  features  will  be  discussed,  but  it  must  be  remem- 
bered that  conditions  observed  in  the  normal  do  not  necessarily  hold 
true  in  the  deformed  spine  of  scoliosis,  although  they  form  the  best 
basis  for  analysis.  The  more  nearly  a  spine  approaches  the  normal, 
the  more  likely  is  such  analysis  to  be  correct. 

SYMMETRICAL  EXERCISES. 
Exercises  in  the  Standing  Position. 

In  all  exercises  given  in  this  position  the  pelvis  should  be  fixed  unless  otherwise 
stated.  It  must  be  remembered  that  exercises  in  this  position  call  into  play  in 
varying  relations  all  muscles  concerned  in  maintaining  the  upright  position,  and 
therefore  cannot  be  as  highly  specialized  as  can  exercises  given  in  the  lying  position. 
It  must  also  be  remembered  that  the  superincumbent  weight  rests  on  the  laterally 
curved  spine,  and  that  the  curves  are  therefore  not  in  as  favorable  a  condition 
in  such  exercises  as  in  the  lying  position.  On  the  other  hand,  they  are  useful  be- 
cause any  improvement  of  scoliosis  must  be  interpreted  as  meaning  improvement 
in  the  upright  position,  and  all  muscles  concerned  in  that  are  therefore  of  impor- 
tance. 

Fundamental  Standing  Position. — The  patient  stands  with  the  knees 
extended,  the  hands  on  the  hips,  the  back  straight,  the  head  erect,  and  the  scapulas 
brought  close  to  each  other.  The  patient  should  not  exaggerate  the  lumbar  curve, 
and  should  press  down  with  both  hands  on  the  hips. 

I.  Shoulder  Raising  and  Sinking. — (i)  From  the  fundamental  standing  position 
the  patient  stretches  the  whole  spine  upward.  The  surgeon  holds  his  hand  slightly 
above  the  patient's  head  and  urges  her  to  stretch  until  she  can  touch  his  hand 
with  her  head,  keeping  both  heels  on  the  ground.  The  position  of  the  hand  is 
made  higher  as  necessary.  (2)  From  the  upward  stretched  position  the  patient 
relaxes  to  the  fundamental  standing  position.  In  count  (i)  the  patient  breathes 
in  and  in  count  (2)  breathes  out  (Fig.  85). 

This  is  a  general  exercise  calling  upon  the  muscles  which  maintain  the  proper 
erect  position,  notably  the  spinal  extensors.  The  elevation  of  the  shoulders  elevates 
and  fixes  the  shoulder-girdle,  giving  a  fixed  point  for  the  pull  of  the  inspiratory 
muscles,  thus  tending  to  increase  chest  capacity,  and  a  general  stretching  of  the 
spine  is  also  made  easier  by  the  fixed  shoulder-girdle.  The  exercise  is  applicable 
to  any  case  of  scoliosis,  especially  to  postural  curves,  as  a  general  mobilizing  and 
corrective  one. 

II.  Trunk  Bending  Forward  with  Shoulders  Raised. — (i)  The  shoulders  are 
raised  as  in  Exercise  I   u)-      (2)   The  patient  bends  her  trunk  forward  to  the  hor- 


128 


TREATMENT. 


izontal  position,  the  spine  being  held  straight  and  the  shoulders  raised,  movement 
occurring  only  in  the  hip-joints.  (3)  The  patient  raises  the  trunk  to  the  upright 
position  with  the  shoulders  still  raised  and  the  spine  straight.  (4)  The  patient 
relaxes  to  the  fundamental  standing  position  (Fig.  86). 

This  combines  the  essentials  of  Exercise  I  with  the  weight  of  the  trunk  thrown 
on  the  extensor  muscles  of  the  back  and  on  the  glutei,  which  must  be  held  con- 


FlG.  85. 


Fig.  87. 


Fig.  SS. 


tracted  to  maintain  the  forward  bent  position  and  which  must  contract  to  bring 
the  trunk  again  into  the  upright  position.  It  has  the  corrective  effect  of  Exercise  I, 
in  addition  to  which  it  is  a  fairly  strong  extensor  spinal  exercise  with  the  lumbar 
curve  flattened.  It  is  a  general  mobilizing  and  corrective  exercise  which  may  be 
safely  used  in  cases  with  a  tendency  to  exaggeration  of  the  lumbar  curve.  The 
patient  inspires  in  (i),  holds  the  breath  during  (2)  and  (3),  and  breathes  out  in 
count  (4). 

The  above  exercises  may  be  modified  and   made   slightly  harder  by  ha\ang 


SYMMETRICAL   EXERCISES. 


129 


the  patient  iilace  both  hands  behind  tlie  neck  with  the  elbows  square,  back  as  far 
as  possible.  This  raises  the  center  of  gravity  of  the  trunk  and  therefore  increases 
the  leverage  against  the  muscles. 

III.  Trunk  Twisting. — Position:  Without  pelvic  fi.xation,  the  feet  parallel 
and  touching,  the  hands  on  the  hips,  the  head  and  spine  erect,  (i)  From  this 
position  the  patient  twists  her  whole  body  as  far  as  possible  to  the  right  or  left, 
the  head  being  turned  as  far  as  possible  in  the  same  direction.  (2)  The  original 
standing  position  is  resumed  (Fig.  87). 

Trunk  rotation  to  the  right  causes  a  left  dorsal  curve  and  vice  versa;  in  addition 
to  this  the  e.xercise  is  intended  to  be  mobilizing  to  the  whole  body,  especially  the 
hip-joints,  and  greater  trunk  excursion  is  possible  with  the  feet  parallel  than  with 
the  legs  rotated  outward.  The  exercise  is  suitable  for  general  spinal  mobilization, 
and  w'hen  given  only  to  one  side  is  a  mild  corrective  exercise  for  lateral  deviation; 
in  the  latter  case  the  pelvis  should  be  fixed  to  localize  the  movement  in  the  spine. 


Fig.  Sg. 


The  effect  of  rotation  upon  the  spine,  especially  in  causing  a  lateral  curve,  may  be  ] 
located  higher  in  the  spine  by  giving  the  rotation  in  the  forward  bent  position,  and  | 
located  lower  by  giving  it  in  the  hyperextended  position.     These  two  variations 
should  be  done  with  the  pelvis  fixed. 

IV.  Trunk   Circling. — Position:    Hands  on    the  hips,  the  trunk  flexed  to  the  \ 
horizontal,  the  spine  straight.     From  this  position  the  patient  describes  a  circle  i 
with  the  trunk  about  a  vertical  axis  passing  between  the  feet.     The  horizontal  ; 
plane  of  the  circle  described  is  quite  irregular,  and  the  movement  is  divided  into, 
four  counts:     (i)  From  the  position  of  forward  bending  the  trunk  passes  to  the 
right  or  left  through  side  bending  with  flexion  and  rotation  to  extreme  side  bending. 
(2)  From  extreme  side  bending  the  circle  is  continued  backward   through  side 
bending  with  its  accompanying  rotation  to  extreme  hyperextension  of  the  median 
plane.     (3)  The  reverse  of  count  (2).     (4)  The  forward  bent  position  is  assumed. 
The  face  is  directed  forward  during  the  entire  exercise  (Fig.  88). 

This  is  a  general  mobilizing  and  strengthening  exercise.     When  a  marked 
lumbar  curve  is  present,  the  exercise  is  preferably  made  unilateral  to  the  side  that 
improves  rather  than  increases  the  lumbar  curve,  e.  g.,  in    a   left  lumbar  curve 
9 


I30 


TREATMENT. 


half  circling  to  the  left  is  preferable  to  the  complete  circle  so  far  as  any  corrective 
aspect  is  concerned. 

V.  Swimming. — Position:  The  patient  bends  fonvard  until  the  trunk  is 
horizontal,  the  arms  are  held  at  the  sides,  the  elbows  flexed,  and  the  hands  together 
against  the  chest,  (i)  The  arms  are  extended  upward  beside  the  head.  (2)  The 
arms  describe  a  half  circle  outward  and  are  brought  to  the  sides  of  the  body.  (3) 
The  arms  return  to  position  (Fig.  89). 

In  this  exercise  the  pelvis  is  flexed  on  the  hip-joints  and  the  weight  of  the 
trunk  is  thrown  forward.  The  extensor  muscles  of  the  spine  and  the  glutei  are 
called  upon  to  maintain  the  position  during  the  movements  of  the  arms.  All  the 
muscles  of  the  shoulder-girdle,  especially  those  concerned  in  drawing  the  scapulae 
together,  take  part  in  the  movement.  This  is  a  general  strengthening  exercise, 
especially  addressed  to  spinal  extensors,  and  is  also  valuable  in  cases  of  flexible 
round  shoulders. 

VI.  Head  Movements  from  the  Fundamental  Standing  Position. — The  head 
and  cervical  spine,  as  far  as  possible,  alone  should  participate  in  these  exercises. 
A.  (i)  Head  flexion,  (2)  original  position.  B.  (i)  Head  hyperextension,  (2)  original 
position.  C.  (i)  Side  bending  of  the  head  to  the  right  or  left,  (2)  original  position. 
D.  (i)  Head  twisting,  right  or  left,  (2)  original  position.  E.  Head  circling  with  the 
face  to  the  front,  a  combination  oi  A,  B,  and  C  following  one  another. 

General  mobilizing  exercises  for  the  cervical  region.  For  corrective  effect 
in  a  cervical  curve  they  should  be  given  only  to  the  side  that  improves  the  curve. 

Exercises  Given  in  the  Horizontal  Position. 
In  this  group  of  exercises  one  set  of  muscles  may  be  more  readily  picked  out 
for  exercise  than  in  the  erect  position.     The  spine  when  prone  is  less  cur\'ed  than 
in  the  upright  position,  and  is  slacker  and  more  easily  capable  of  side  displace- 


J 


Fig.  90. 

ment.  The  fact  that  symmetrical  hyperextensions  are  so  much  used  for  their  cor- 
rective effect  is  explained  by  their  empirical  value  and  by  anatomical  reasons  (page 
35)- 

Lying   on    the   Face. — \TI.    Trunk    Raising. — Position:    The    patient    lies 
face  downward  on  a  table  with  the  spine  straight,  the  hands  on  the  hips,  the  scap- 


SYMMETRICAL   EXERCISES. 


131 


ulae  approximated  to  each  other,  the  toes  brought  over  the  end  of  the  table,  and 
the  legs  secured  to  the  table  by  a  strap  passing  around  the  table  and  legs  just  above 
the  ankles,  or  the  legs  may  be  held  by  the  hands  of  an  assistant,  (i)  The  patient 
inspires  and  raises  the  trunk  from  the  table,  hyperextending  the  spine  as  far  as 
possible,  keeping  the  head  back  and  the  face  up,  with  the  elbows  still  held  well 
back.     (2)  The  patient  breathes  out  and  sinks  to  the  original  position  (Fig.  90). 

This    is   an    extension    of    the    spine   from    its    normal    position   to   extreme 
hyperextension  in  which  the  spinal  motion  occurs  largely  below  the  tenth  dorsal 


Fig.  91. 


Fig.  92. 


vertebra,  where  hyperextension  anatomically  takes  place.  The  weight  of  the 
trunk  is  raised  by  action  of  the  back  extensor  muscles,  which  are  very  generally 
called  into  play.  It  is  a  general  strengthening  exercise  for  these  muscles,  but  in 
cases  with  marked  increase  of  the  lumbar  curve  it  must  not  be  used  to  increase 
this,  in  such  cases  Exercise  II  being  available.  The  latter  is  probably  a  weaker 
exercise,  because  in  it  the  extensor  muscles  do  not  contract  to  their  fullest  extent. 
The  exercise  may  be  made  harder  by  placing  the  hands  behind  the  neck  and  squar- 
ing the  elbows  back  or  by  extending  the  arms  beside  the  head,  which  raises  the 
center  of  gravity  (Fig.  91). 


13^ 


TREATMENT. 


The  above  may  be  modified  in  the  following  manner:  The  patient  clasps  his 
hands  behind  his  back  above  the  level  of  the  waist-line,  with  elbows  flexed  and 
hand  closed  against  the  back,  and,  as  he  hyperextends  his  trunk,  stretches  his 
arms  backward  forcibly,  extending  the  elbows,  and  keeping  the  hands  clasped. 
By  this  modification  the  scapulae  and  shoulder-joints  are  carried  back  and  the 
hyperexterision  done  with  an  improved  position  of  the  shoulders.  This  is  par- 
ticularly suited  to  round  shoulders. 


Fig.  93. 


Fig.  94. 


VIII.  Trunk  Raising  with  Dumb-bells  and  Staff. — These  are  merely  varieties 
of  Exercise  VII,  in  which  the  position  of  the  shoulders  is  modified  by  means  of 
dumb-bells  or  wands  held  in  the  hands,  or  in  which  the  center  of  gravity  is  changed 
by  the  dumb-bells,  making  the  exercise  harder,  (a)  The  patient  grasping  dumb- 
bells, places  them  together  against  the  back  and  as  high  up  as  possible,  (b)  The 
patient  grasping  the  dumb-bells  with  the  arms  extended  above  the  head,  circum- 
ducts the  arms  during  the  two  counts  of  the  exercise,  (c)  A  staff  is  grasped  in 
both  hands  by  the  patient,  who  lies  with  arms  e.xtended  above  the  head,  hands 
palms  down  and  rather  widely  separated.  This  position  of  the  arms  is  main- 
tained during  the  exercise,     {d)  This  exercise  differs  from  the  last  (c)  in  that  the 


SYMMETRICAL   EXERCISES. 


133 


Staff  is  brought  over  the  head  and  down  behind  the  scapula;  during  "raising," 
and  the  original  position  resumed  during  "sinking"  (Figs.  92-94). 

These  exercises  increase  the  muscular  effort  elicited  by  Exercise  VII  by  chang- 
ing the  center  of  gravity;  most  of  them  call  into  action  the  muscles  which  approx- 
imate the  scapulae  and  tend  to  stretch  contractions  holding  them  in  a  forward 
position.  Probably  in  some  an  element  of  forced  hyperextension  of  the  dorsal 
spine  is  present.  They  find  their  use,  consequently,  in  addition  to  scoliosis, 
in  cases  of  both  flexible  and  resistant  round  shoulders.  The  individual  applica- 
tion must  be  decided  by  the  special  characteristics  of  the  case.  ' 

Exercises  Lying  on  the  Face,  the  Trunk  Projecting  over  the  End. 
of  the  Table. — The  legs  rest  on  the  table,  the  surgeon  making  the  ankles  secure-^ 
by  means  of  a  strap  or  by  holding  them.  The  body  above  the  hip-joints  hangs 
over  the  table  end,  head  downward.  The  hands  are  placed  behind  the  neck  with 
the  elbows  squared  back.  I 


Fig.  95. 


Fig.  96. 


IX.  Trunk  Raising  from-  Head  Downward  Position. — (i)  The  patient  in- 
spires, and  raises  the  trunk  as  far  as  possible  by  hyperextending  the  hip-joints 
and  the  spine.  (2)  During  expiration  she  sinks  to  the  primary  position.  The 
spine  should  be  kept  in  the  mid-plane  and  the  head  not  allowed  to  flex  (Fig.  95). 

This  is  a  spinal  extension  movement  mostly  without  superincumbent  weight, 
beginning  at  forward  flexion  and  ending  in  marked  hyperextension,  calling  the 
extensor  muscles  into  activity  from  a  stretched  to  a  completely  contracted  condi- 
tion. It  thus  combines  the  range  of  motion  in  Exercise  II  with  that  of  Exercise 
VII.  It  is  a  heavier  exercise  than  either.  From  the  start  of  the  exercise  till  the 
horizontal  position  is  reached  the  spinal  extensors  and  glutei  are  the  muscles  chiefly 
active,  as  the  maintenance  of  balance  does  not  require  the  contraction  of  other 
trunk  muscles.  The  exercise  may  be  made  easief  by  placing  the  hands  on  the 
hips.  It  is  of  use  as  a  general  strengthening  e.xercise  for  the  back  muscles  in  any 
case  where  the  patient  is  strong  enough  to  take.  it. 

X.  Trunk  Circling. — The  position  is  the  same  as  in  Exercise  IX.  The  exer- 
cise is  done  in  four  counts,  as  described  under  Exercise  IV  (Fig.  96). 

This  is  a  heavier  exercise  than  I\'  because  the  weight  of  the  trunk  is  a  factor 


134 


TREATMENT. 


entering  into  each  component  of  the  movement.     For  corrective  effect  it  shoiild 
be  given  only  to  the  side  that  improves  the  lateral  curve. 

XI.  Sivimming. — This  exercise  is  done  in  the  same  way  as  Exercise  V,  except 
that  the  patient  first  raises  his  trunk  as  high  as  possible,  and  holds  the  position 
while  he  goes  through  the  movements  of  swimming  (Fig.  97). 

It  differs  from  Exercise  V  because  the  spine  is  held  in  a  position  of  hyperexten- 
sion,  and  is  not  flexed  on  the  pelvis.     It  thus  exercises  chiefly  the  spinal  extensors 


Fig.  97. 


/       ■> 


in  a  position  necessitating  their  maximum  contraction.     It  is  not  suitable  to  cases 
with  increased  lumbar  curve. 

Exercises  Lying  on  the  Back. — The  patient  lies  on  a  table  or  on  the  floor 
with  the  head,  trunk,  and  legs  straight,  and  the  feet  secured  either  by  a  strap  or 
by  being  held.     The  arms  are  folded  on  the  chest. 

I  XII.  Trunk  Raising  to  Sitting  Position. — (i)  The  patient  rises  slowly  to  the 

i     sitting  position  with  the  spine  stiff  and  not  allowed  to  flex.     (2)  The  patient  sinks 

to  the  primary  position  with  the  spine  still  stiff,  the  head  touching  the  table  before 

the  back  (Fig.  98). 


SUSPENSION. 


135 


The  exercise  is  made  easier  by  placing  the  hands  on  the  hips,  and  harder  by 
placing  the  hands  behind  the  neck  with  the  elbows  squared  back.  The  upright 
position  is  brought  about  by  the  contraction  of  the  abdominal  muscles,  which 
aid  in  maintaining  the  upright  position,  and  require  exercise  in  cases  of  prominent 
abdomen  and  of  increase  of  the  lum- 
bar physiological  curve  accompanying 
scoliosis  and  round  shoulders. 

Exercises  in  the  Suspended  Posi- 
tion. 

The  patient  stands  erect,  and  the 
head  is  pulled  vertically  upward  by 
means  of  a  Sayre  head-sling,  which 
embraces  the  chin  and  occiput.  Trac- 
tion should  be  made  by  a  compound 
pulley,  and  the  patient  or  the  surgeon 
may  hold  the  rope.  Suspension  is 
mildest — (i)  when  the  feet  are  not 
made  to  leave  the  floor;  next  in  grade 
comes  (2)  the  position  of  tiptoe  in- 
duced by  the  traction,  and  (3)  a  greater 
pull  is  secured  by  lifting  the  whole 
body  until  the  feet  swing  free.  In  this 
case  the  traction  force  equals  the  body- 
weight.  The  maximum  traction  can 
be  secured  (4)  by  strapping  the  thighs 
down  to  a  seat  on  which  the  patient 
sits.  An  upward  pull  greater  than 
the  body-weight  can  now  be  exerted 
on  the  head  (Fig.  99). 

Head  suspension  is  a  passive 
stretching  of  the  spine,  corrective 
through  its  entire  length,  tending  to 
improve  both  rotation  and  side  devi- 
ation at  the  curves,  but  exercising 
still  more  force  upon  the  more  nearly 
normal  parts  of  the  spine  because 
the  latter  are  more  movable.  Sus- 
pension by  the  arms  is  less  efificient, 
and  does  not  affect  the  cervical  ver- 
tebrae as  does  head  suspension.  Hanging  is  a  generally  useful  and  purely  mobil- 
izing procedure  suitable  to  any  case,  slight  or  severe. 

If  it  is  desired  to  make  hanging  exercises  more  locally  corrective  in  the  dorsal 
region,  the  patient  should  hang  by  the  hands  from  a  bar,  the  hand  on  the  convex 
side  of  the  lateral  curve  grasping  a  loop  on  the  bar  which  is  at  least  two  inches 
below  it.     By  this  means  the  concave  side  will  be  subjected  to  a  greater  stretching. 

XIII.  Hanging — Body  Circling.— In  the  original  position  the  patient  is  not 
suspended  by  the  head-sling,  but  the  sling  is  lax  and  the  feet  touch  the  floor.  The 
patient  then  swings  forward  until  restrained  by  the  suspension  apparatus,  and' 


Fig.  99. — Head  Traction. 


136 


TREATMENT. 


then  circles  to  the  right,  backward  and  forward,  and  to  the  left,  gaining  a  mo- 
mentum with  which  to  continue  the  circling.  After  the  patient  has  circled  to  the 
right  the  desired  number  of  times  she  reverses  the  direction  and  circles  a  desired 
number  of  times  to  the  left.  In  this  exercise  the  body  is  swung  about  the  feet  as  a 
pivot.  The  feet  are  kept  in  one  place  on  the  floor,  the  trunk  describing  a  circle 
which  involves  the  entire  range  of  side  bending  and  forward  and  V:)ackward  motion. 

This  is  a  general  mobilizing  exercise  for  the  entire  spine,  and  may  be  modified 
by  being  given  only  to  the  side  that  improves  the  lateral  curve  to  increase  its  correc- 
tive effect. 

XIV.  Hanging — Pelvic  Rotation. — The  patient  hangs  by  both  hands  from  a 
bar  and  rotates  the  pelvis  and  legs  rapidly  and  forcibly  first  to  the  right  and  then 
to  the  left,  alternating  the  two  rotations  in  succession. 

The  exercise  is  intended  to  mobilize  the  lower  dorsal  and  upper  lumbar  region. 


Miscellaneous  Symmetrical  Exercises. 

XV.  Heavy  Weight  Raising^  (Teschner). — The  patient  stands  facing  a  table, 
which  touches  the  front  of  the  thighs  or  pelvis,  against  which  she  rests.     She  then 

raises  slowly  a  heavy  bar,  weighing  from  10  to  30  or 
more  pounds,  over  the  head  as  high  as  the  arms  will 

'■ •'  : ■-  ,•  -'--".:"-"-:"-'-'.::;:::'        reach,  keeping  the  eyes  fixed  on  the  middle  of  the 

;  i  ;  ;  bar  and  keeping  the  bar  horizontal.     It  is  then  low- 

ered slowly,  but  should  be  held  or  rested  at  the  level 
of  the  shoulders  and  not  allowed  to  drag  on  the 
arms.  The  exercise  is  repeated  as  often  as  may  be. 
The  patient  should  use  as  hea^y  a  bar  as  can  be  put 
up  steadily  and  which  produces  a  corrective  effect 
on  the  curve  when  the  point  of  upward  stretch  is 
reached.  The  weight  should  be  steadily  increased 
as  the  muscular  capacity  of  the  patient  increases  (Fig. 
100). 

The  exercise  tends  to  develop  all  the  muscles  of 
the  trunk,  as  its  correct  performance  necessitates  a 
contraction  of  the  muscles  maintaining  the  erect 
position.  It  is  not  particularly  corrective  to  the 
curve,  but  fills  out  the  flanks,  improves  the  body- 
^'^'  '°°'  outline,  and  tends  to  strengthen  the  muscles  main- 

taining a  correct  upright  attitude,  in  this  way  tend- 
ing to  fix  the  improved  position.  It  is  a  developmental  exercise  suited  to  any 
curve,'  of  retentive  rather  than  corrective  value,  and  therefore  best  used  as  sup- 
plementary to  other  and  more  corrective  work. 

XVI.  Weight  Carrying  on  the  Head. — A  bag  filled  loosely  with  sand,  weighing 
from  3  to  15  pounds,  is  placed  on  the  top  of  the  patient's  head,  and  she  walks 
slowly  to  and  fro  with  the  arms  preferably  clasped  behind  the  neck  and  the  elbows 
squared  back.  The  exercise  may  be  made  more  difficult  by  having  the  patient 
walk  on  tiptoe.  The  attitude  assumed  should  be  as  erect  as  possible  and  the 
weight  as  heavy  as  can  be  carried  steadily. 

It  is  a  matter  of  common  information  that  the  habitual  carrying  of  baskets 
and  loads  upon  the  head  induces  an  erect  carriage  and  a  straight  spine.  The 
presence  of  weight  upon  the  head   necessitates  getting  the  spine  as  straight  as 


'Teschner:  "Ann.  of  Surgery,"  Aug.,  1S95 :  "Orth.  Trans.,"  vol.  ix. 


ASYMMETRICAL   EXERCISES.  I37 

possible  under  the  weight,  as  it  is  thus  most  economically  carried,  and  this  in- 
stinctive adjustment  to  superincumbent  weight  is  depended  on  for  its  corrective 
effect.  To  carry  a  weight  on  the  head  with  the  spine  not  held  in  its  best  position 
by  muscular  effort  would  be  undesirable.  The  exercise  is  suited  to  mild  cases 
with  noticeable  bad  carriage  and  poor  balance. 

XVII.  Mirror  Self-corrective  Exercise.— The  patient,  bared  to  the  hips,  faces 
a  mirror  in  front  of  which  hangs  a  plumb-line.  The  patient  then  stands  in  such 
a  position  that  the  plumb-line  cuts  the  middle  of  the  pelvis,  and  by  a  muscular  effort 
brings  tlie  middle  of  the  thorax  and  the  vertical  line  of  the  face  as  nearly  as  possible 
under  the  plumb-line,  bringing  thus  three  important  landmarks  into  the  median 
line  of  the  body,  thus  securing  an  improved  position.  This  is  held  for  a  few  seconds 
and  then  the  relaxed  position  resumed.  The  exercise  is  repeated  several  times, 
the  improved  position  being  held  longer  each  time. 

The  exercise  is  a  muscle  training  and  is  not  in  any  way  a  mobilizing  exercise, 
but  enables  the  patient  to  associate  a  certain  position  with  a  certain  muscular  effort, 
and  is  of  great  value  in  enabling  patients  to  identify  by  muscular  sense  the  cor- 
rected position.  The  exercise  requires  but  little  effort  and  may  be  done  at  home 
without  assistance.  It  may  be  modified  in  various  ways  by  adding  free-arm, 
staff,  or  dumb-bell  exercises,  which  change  the  center  of  gravity,  strengthen 
muscles  approximating  the  scapulae,  and  prolong  the  corrected  attitude. 


ASYMMETRICAL  EXERCISES. 

XVIII.  Hip  Sinking  (Hoffa). — Position:  From  the  fundamental  standing 
position  the  patient  advances  the  foot,  on  the  side  opposite  to  the  convexity  of  the 
lateral  curve,  forward  and  outward  about  two  foot-lengths,  (i)  The  patient  bends 
the  forward  knee,  sinking  the  hip  on  that  side.  (2)  The  patient  resumes  the  pri- 
mary position  (Fig.  loi). 

A  passive  side  correction  of  the  lumbar  curve,  due  to  a  lowering  of-  the  pelvis 
on  the  side  of  the  advanced  leg  when  the  knee  is  bent.     Suitable  for  lumbar  curves. 

XIX.  Self-correction  (Lorenz). — The  patient  assumes  the  fundamental  stand- 
ing position  and  places  the  hand  of  the  side  to  which  the  dorsal  spine  is  convex 
upon  the  side  of  the  thorax  opposite  to  the  greatest  dorsal  curve;  the  other  hand  is 
then  placed  on  the  ilium,  (i)  By  a  side  thrust  of  the  hand  on  the  thorax  the 
patient  corrects  or  overcorrects  the  dorsal  curve,  maintaining  the  correction  for 
a  few  seconds.  (2)  The  patient  relaxes  to  the  primary  position.  The  exercise 
may  be  modified  by  placing  the  hand  on  the  side  to  which  the  dorsal  spine  is  con- 
cave on  the  top  of  the  head,  as  it  thus  tends  to  raise  a  low  shoulder.  The  rest  of 
the  exercise  is  performed  as  described  (Fig.  102). 

A  side  thrust  of  the  dorsal  spine  with  pressure  applied  to  the  convexity  of  the 
dorsal  curve  against  resistance  furnished  by  the  other  hand  on  the  ilium  or  the 
head.  Suitable  for  dorsal  scoliosis,  but  not  powerful,  and  useful  as  a  means  of 
stretching;  chiefly  good  because  it  can  be  done  by  the  patient  unaided  at  frequent 
intervals.  Exercises  XVIII  and  XIX  may  be  combined  for  a  double  curve  with 
one  element  dorsal  and  the  other  lumbar. 

XX.  Hip  Sinking  fr.^m  Stool. — Position:  The  patient  stands  erect  on  a  stool 
on  one  foot  (the  foot  on  the  side  of  the  convexity  of  the  curve),  (i)  The  patient 
lets  the  free  leg  sink  as  much  as  possible,  thus  lowering  the  pelvis  and  hip  on  that 
side.  The  knee  of  the  supporting  leg  must  be  kept  straight.  (2)  The  patient 
resumes  the  original  position  (Fig.  103). 


138 


TREATMENT. 


A  passive  side  stretching  of  the  lumbar  curve  suitable  for  lumbar  scoliosis. 
The  leg  and  pelvis  drag  down  on  the  side  of  the  concavity  of  the  lateral  curve, 
tending  to  stretch  contracted  structures  and  straighten  the  curve. 

XXI.  Trunk  Hyperextension  with  Side  Bending — Lying  on  the  Face. — -The 
patient  lies  face  downward  on  a  table  or  on  the  floor  as  described  in  Exercise 
VII.  (i)  The  trunk  is  raised  from  the  table  as  far  as  possible  by  hyperextending 
the  spine.  (2)  From  this  position  the  trunk  is  bent  to  the  side  toward  which  the 
lumbar  curve  is  convex.  (3)  Position  i  is  resumed.  (4)  The  prone  lying  posi- 
tion is  resumed  (Fig.  104). 

This  exercise  is  an  active  lateral  flexion  of  the  spine  in  the  position  of  hyperex- 
tension. As  hyperextension  locks  the  dorsal  region  against  side  flexion,  the  move- 
ment is  almost  wholly  confined  to  the  lumbar  region.  If  there  is  a  right  dorsal 
curve  in  connection  with  a  left  lumbar  curve,  bending  to  the  left,  while  it  corrects 
the  lumbar  curve,  does  not  at  the  same  time  greatly  increase  the  dorsal  curve, 


Fig.  ioi. 


Fig.  102. 


Fig.  103. 


as  that  part  of  the  spine  is  locked  against  side  bending.  The  exercise  is,  therefore, 
suited  not  only  to  lumbar  curves,  but  especially  to  compound  curves  in  both  dorsal 
and  lumbar  regions. 

XXII.  Drawing  up  the  Hip — Lying  on  the  Face. — Position:  The  patient  lies 
prone  on  a  table,  holding  the  end  with  both  hands,  the  arms  extended  and  the  spine 
and  legs  in  a  straight  line,  (i)  The  surgeon  grasps  the  ankle  on  the  side  of  the 
lumbar  convexity  and  resists  while  the  patient  draws  the  hip  up  as  far  as  she  is  able, 
the  knee  being  kept  straight.     (2)  Position  i  is  resumed  (Fig.  105). 

The  approximation  of  the  side  of  the  pelvis  and  the  thorax  on  the  side  to  which 
the  lumbar  curve  is  convex  is  brought  about  by  an  active  contraction  of  the  muscles 
on  the  convex  side  of  the  lumbar  curve  which  it  is  desirable  to  develop.  The  amount 
of  work  thrown  on  these  is  determined  by  the  amount  of  traction  made  on  the  ankle. 
The  exercise  is  suited  to  cases  of  lumbar  curves  or  to  the  lumbar  element  of  com- 
pound dorsal  and  lumbar  curves. 

XXIII.  Side  Flexion  of  the  Trunk  from  the  Side-lying  Position. — Position: 
The  patient  lies  on  a  table  with  the  concavity  of  the  lateral  curve  downward  and 
the  trunk  projecting  over  the  edge  of  the  table  above  the  pelvis,  the  patient  being 


ASYMMETRICAL   EXERCISES. 


139 


Fig.  104. 


Fig.  105. 


140 


TREATMENT. 


supported  in  this  position,  and  the  ankles  secured  by  means  of  a  strap.  The  spine 
is  held  in  medium  extension,  the  upper  hand  on  the  hip  and  the  lower  hand  on  the 
back  of  the  neck,  (i)  The  trunk  is  bent  laterally  and  upward  as  far  as  possible. 
(2)  The  original  supported  position  is  resumed  (Fig.  106). 

In  this  exercise  the  weight  of  the  trunk  is  thrown  on  the  muscles  of  the  convex 
side  of  the  lateral  curve.  The  raising  of  the  trunk  tends  both  to  diminish  a  curve 
existing  near  the  dorsolumbar  junction  and  to  exercise  strongly  the  muscles  which 
aid  in  its  correction.     It  is  suited  to  total,  lower  dorsal  and  dorsolumbar  curves. 

XXIV.  Self-correction  with  Arms  Extended  Behind  Back  (Mikulicz). — The 
patient  stands  without  pelvic  fixation  with  the  arms  hanging  behind  the  back,  with 
extended  elbows,  and  the  hands  clasped  loosely  with  the  palms  together,  (i)  The 
patient  bends  forward,  flexing  the  spine.     (2)  The  patient  then  straightens  the 


Fig.  107. 


arms  with  force,  getting  the  shoulders  as  far  back  as  possible  and  stretching  the 
hands  down,  and  then  describes  a  half  circle  to  the  right  or  left  to  the  hyperextended 
median  position.     The  bend  is  to  the  right  in  right  curves  and  vice  versa  (Fig.  107). 

The  exercise  is  a  side  flexion  made  in  the  direction  that  improves  the  lateral 
curve,  with  the  shoulders  in  a  corrected  position.  The  arm  on  the  convex  side 
presses  against  the  rotated  thorax  and  has  some  corrective  efi^ect.  The  exercise 
is  particularly  useful  in  dorsal  scoliosis  with  increase  of  the  dorsal  physiological 
curve  (kyphoscoliosis). 

I  XXV.  Trunk  Bending  to  Both  Sides  with  Hand  Pressure  {Mikulicz). — Posi- 
tion: In  the  case  of  a  right  dorsal  left  lumbar  curve  the  patient  places  the  right 
hand  on  the  prominence  of  the  ribs  just  under  the  shoulder-blade,  and  the  left  above 
the  ilium  on  the  lumbar  curvature,  (i)  She  then  bends  the  body  slowly  to  the 
right  side,  while  the  right  hand  and  thumb  press  against  the  dorsal  prominence.  (2) 
The  upright  position  is  resumed.  (3)  The  patient  bends  to  the  left  and  backward, 
pressing  with  the  left  hand  against  the  lumbar  curve.  (4)  The  upright  position  is 
resumed  (Fig.  108). 

This  is  a  combined  mild  active  and  passive  correction  for  a  double  cur\'e.  Op- 
posing forces  are  applied  to  the  convexities  of  the  curves,  thus  tending  to  straighten 


ASYMMETRICAL   EXERCISES. 


141 


the  spine,  which  is  at  the  same  time  bent  by  means  of  muscular  action,  first  to  the 
side  of  the  convexity  of  the  dorsal  curve  and  then  to  the  side  of  the  convexity  of  the 
lumbar  curve. 

XXVI.  Passive  Head  Side  Bending. — Position:  The  patient  stands  with  the 
hand  on  the  side  of  the  concavity  of  the  lateral  curve  against  the  side  of  the  head 
above  the  ear.  (i)  The  head  is  pushed  as  far  as  possible  to  the  side  that  corrects 
the  curve.     (2)  The  original  position  is  resumed  (Fig.  109). 

A  passive  correction  of  the  cervical  lateral  curve  by  a  side  bend  of  the  upper 
part  of  the  cervical  region  which  tends  to  diminish  the  curve.  Of  use  in  cervical  and 
cervicodorsal  curves,  either  alone  or  existing  in  combination  with  others. 

XXVII.  Trunk  Raising  with  Asymmetrical  Position  of  Staff — from  Prone  Lying 
Position. — Position:  The  one  described  for  exercises  with  the  patient  lying  on  the 
face  (Exercise  VIII)  with  a  staff  grasped  in  both  hands,  the  arms  being  extended 
beside  the  head,     (i)  The  trunk  is  raised  from  the  table  and  the  staff  brought  over 


/ 


Fig.  I 


Fig.  109. 


behind  the  head  obliquely,  the  hand  on  the  side  of  the  convexity  of  the  curve  being 
carried  down  toward  the  feet  and  the  other  carried  up  over  the  head  until  the  staff 
is  brought  as  nearly  as  possible  into  the  long  axis  of  the  body  and  pressed  against  the 
back.    (2)  By  a  reversal  of  the  movement  the  original  position  is  resumed  (Fig.  1 10). 

The  scapula  on  one  side  is  raised,  and  the  position  of  the  staff  tends  to  correct 
an  existing  curve  in  the  dorsal  region.  The  exercise  amounts  to  a  spinal  hyper- 
extension  in  a  corrected  position  of  the  dorsal  spine.  The  exercise  is  suited  to  total 
curves,  to  simple  dorsal  curves,  and  to  compound  dorsal  and  lumbar  curves. 

XXVIII.  Partial  Suspension  by  One  Arm  with  Other  Arm  and  Leg  Locked. — - 
Position:  The  patient  standing  by  a  ladder  or  under  a  bar  that  can  be  reached 
without  rising  on  the  toes,  grasps  one  rung  of  the  ladder  or  the  bar  with  the  hand  of 
the  side  to  which  the  spine  is  concave.  On  the  opposite  side,  the  convex,  the  arm 
passes  under  the  knee,  the  thigh  being  flexed  at  the  hip,  and  the  shoulder  and  pelvis 
are  thus  approximated,  (i)  The  patient  thus  standing  on  one  leg  fle.xes  that  knee 
and  allows  the  body-weight  to  come  upon  the  arm.  (2)  The  original  position  is 
resumed  (Fig.  iii). 

When  the  arm  is  placed  under  the  knee  the  pelvis  and  shoulder  are  approxi- 
mated on  that  side  and  the  spine  made  convex  to  the  other  side  as  far  as  it  will  go. 


142 


TREATMENT. 


The  structures  on  the  concave  side  are  thus  put  on  the  stretch  and,  by  allowing  the 
body-weight  to  come  on  the  arm  holding  to  the  ladder,  a  further  stretching  force  is 
exerted  on  the  structures  on  the  concave  side.  The  exercise  is  suited  to  total  and 
dorsal  curves. 

Creeping  Exercises  (Klapp). — In  these  exercises  the  patient  supports  the 
trunk  in  a  horizontal  position  with  the  hands  and  knees  or  feet  on  the  floor.  The 
hands,  knees,  and  toes  should  be  protected  by  leather  pads  which  are  strapped  on. 

XXIX.  Symmetrical  Creeping. — The  hand  and  knee  of  the  right  side  are  placed 
close  together  with  the  hand  to  the  outer  side  of  the  knee,  the  head  is  twisted  with  the 
face  to  the  right,  and  the  trunk  is  rotated  with  the  left  shoulder  upward.  The  left 
arm  is  extended  beyond  the  head  and  the  hand  placed  on  the  floor,  palm  down  and 
fingers  forward,  as  far  forward  as  possible  and  directly  in  front  of  the  right  knee.  The 
left  knee  is  placed  as  far  back  and  as  near  the  median  line  as  possible;  the  spine  is 
strongly  bent  to  the  right.  The  creeping  consists  of  forward  locomotion  by  a  series  of 
reversals  and  regainings  of  the  position  described.  The  mechanism  of  the  first 
reversal  is  as  follows:  the  left  knee  is  drawn  forward  to  the  inner  side  of  the  left 
hand  in  its  original  place  and  position,  the  right  arm  is  extended  above  the  head,  and 
the  hand  placed  as  far  in  front  of  the  left  knee  as  possible  with  the  palm  down  and 


Fig.  no. 


Fig.  III. 


fingers  front.  At  the  same  time  the  spine  is  rotated  to  bring  the  right  shoulder  high, 
the  face  is  twisted  to  the  left,  and  the  spine  flexed  to  the  left.  The  restoration 
to  the  first  position  is  secured  by  again  moving  the  back  knee  (right)  and  the  back 
hand  (left)  (Fig.  112). 

This  is  a  general  muscle-strengthening  and  spine-mobilizing  exercise.     It  is 
comparatively  mild  and  may.be  continued  for  long  periods  of  from  twenty  to  forty 
minutes.     It  is  said  to  be  of  value  to  lengthen  shortened  muscles  and  ligaments  on 
/  the  concave  side.     Symmetrical  creeping  is  properly  that  which  is  done  rapidly,  / 
'  and  is  of  most  value  in  restoration  of  flexibility. 

A  modification  is  made  by  creeping  slowly,  holding  each  position  and  putting 
orce  into  the  stretching,  usually  holding  the  position  longest  which  stretches  the  con- 
cavity of  the  most  marked  curve  (Fig.  113).  Another  modification  is  creeping  in  place, 
which  differs  from  the  above  in  that  the  patient  does  not  attempt  locomotion.  The 
position  is  somewhat  as  above  except  that  the  fingers  of  both  hands  are  placed  on 
the  floor,  pointing  opposite  to  the  side  to  which  the  face  looks.     The  trunk  is  rotated 


CREEPING   EXERCISES. 


143 


till  the  side  with  the  forward  arm  is  uppermost,  and  the  arm  is  carried  directly  over 
the  head  while  the  under  arm  is  flexed  at  the  elbow  which  points  to  the  side  toward 
which  the  face  is  turned;  the  posterior  knee  is  straightened,  and  the  foot  only  of 
that  limb  touches  the  floor.     The  patient  then  endeavors  to  look  upward  beneath 


Fig.  112. 


Fig.  113. 


Fig.  114. 


the  forward  reaching  arm  (Fig.   114).     This  is  best  employed  as  an  asymmetrical 
exercise  to  correct  the  dorsal  convexity  and  stretch  the  side  of  the  concavity. 

XXX.  Creeping  Sidewise. — There  is  a  third  asymmetrical  variation  in  "creeping 
sidewise"  toward  the  side  showing  the  concavity  of  the  curve  to  be  corrected,  for 


144 


TREATMENT. 


example,  in  a  left  total  curve.  The  patient  creeps  sidewise  to  the  right.  The  left 
hand  and  knee  are  placed  under  the  trunk,  and  as  far  as  possible  to  the  right  of  the 
right  hand  and  knee.  The  right  hand  and  knee  are  then  advanced  to  the  right  and 
the  above  is  repeated.     The  face  should  look  to  the  left  (Fig.  115). 

This  is  a  corrective  exercise  similar  to  other  forms  of  creeping,  and  may  also  be 
used  for  dorsal  curves  as  well  as  for  those  of  the  total  type. 


Fig.  115. 


PASSIVE  STRETCHING  OF  THE  SPINE. 

Increased  mobility  of  the  stiffened  parts  of  the  spine  and  stretching 
of  the  contracted  structures  is  in  all  but  the  milder  cases  of  structural 
scoliosis  more  easily  to  be  obtained  by  intermittent  passive  stretching 
in  apparatus  than  by  active  or  passive  gymnastic  exercises  without 
apparatus. 

The  following  considerations  bear  on  the  use  of  force  for  stretching 
in  both  intermittent  stretching  and  in  forcible  correction. 

Such  passive  stretching  of  the  spine  is  commonly  secured  by  hang- 
ing by  the  arms  from  a  bar,  but  preferably  by  upward  traction  on  the 
head  by  means  of  a  Sayre  head-sling.  A  pull  in  the  length  of  the  ver- 
tebral column  is  not,  however,  an  economical  use  of  force. 

The  least  economical  use  of  force  in  straightening,  for  example,  a  bent  stick  is 
to  pull  the  two  ends  away  from  each  other,  i.  e.,  to  straighten  it  by  a  pull  in  its  length. 
The  most  economical  use  of  force  is  to  take  it  by  the  two  ends  and  press  the  point 
of  greatest  convexity  against  some  resisting  point  which  shall  push  it  straight.  The 
relative  force  exerted  will  be  recognized  if  one  is  reminded  how  easy  it  is  to  break 
a  bent  stick  by  striking  it  on  the  knee  while  one  hand  holds  each  end  and  how  very 
difficult  it  would  be  to  break  the  same  stick  by  a  pull  in  its  length. 

Again,  if  one  wishes  to  secure  the  greatest  side  displacement  in  a  flexible  rod, 
such  displacement  is  more  easily  secured  when  the  rod  is  not  stretched  in  its  length. 
If  a  rubber  tube,  for  example,  is  fastened  to  a  table  by  two  pins,  one  at  each  end 
and  is  not  put  on  the  stretch,  the  middle  of  it  can  easily  be  pulled  an  inch  to  one  side 
by  the   forefinger.     If,  however,  it  is  pinned  to  the  table  by  two  pins  separated, 


PASSIVE    STRETCHING.  I45 

enough  to  hold  it  on  the  stretch,  it  will  require  much  more  force  to  displace  it  one 
inch  to  the  side.     The  same  is  true  of  a  strip  of  sponge  rubber  or  a  piece  of  rattan. 

To  be  sure  that  this  theoretical  consideration  applied  to  the  human  spine  the  fol- 
lowing experiment  was  made  at  the  Harvard  Medical  School  by  the  courtesy  of 
Prof.  Thomas  Dwight. 

A  young  male  cadaver  was  laid  on  the  face,  and  straps  passed  around  the  body 
at  the  level  of  the  right  shoulder  and  the  right  hip.  These  straps  were  then  fastened 
to  the  left  side  of  the  table,  holding  the  shoulder  and  hip  against  pressure  from  the 
left.  A  strap  was  then  passed  around  the  left  side  of  the  thorax  and  by  means  of  a 
spring  balance  pulled  to  the  right.  The  side  deviation  of  the  spine  was  then  mea- 
sured at  four  levels,  the  measurements  being  taken  from  a  base-line  connecting  the 
cervical  spine  and  the  sacrum.  The  measurements  were  all  made  from  pins  driven 
into  the  spinous  processes.  Three  experiments  were  made  with  a  side  pull  of  25 
pounds  and  the  results  were  recorded. 

A  Sayre  head-sling  was  then  put  around  the  head  of  the  cadaver  still  lying  on 
the  face,  and  a  traction  force  of  75  pounds  was  made  in  the  length  of  the  spine,  the 
feet  of  the  cadaver  being  fastened  to  the  table.  While  the  traction  on  the  head  was 
thus  in  force  the  same  side  pull  of  25  pounds  was  made  as  before  and  the  results 
noted.  Two  experiments  of  this  sort  were  made.  It  was  found  that  the  spine  with- 
out traction  was  displaced  to  the  side  nearly  twice  as  far  by  a  definite  side  pull 
as  by  the  same  amount  of  side  pull  when  traction  was  being  made. 

A  confirmatory  experiment  was  made  on  a  healthy  boy  of  fifteen,  using  75 
pounds  of  head  traction  and  15  pounds  of  side  pull.     The  result  was  the  same. 

The  conclusion  is  that  extension  of  the  spine  by  an  upward  pull  on 
the  head  is  a  corrective  force  in  the  normal  spine,  but  that  much  more 
force  is  required  to  accomplish  a  certain  amount  of  side  correction  than 
is  the  case  if  the  force  is  applied  from  the  side. 

The  other  conclusion  is  that  to  secure  the  maximum  of  side  displace- 
ment from  a  given  amount  of  side  pressure  the  spine  must  be  slack 
and  not  stretched  in  its  length. 

Apparatus  for  the  purpose  has  been  devised,  and  is  known  as  the 
Weigel-Hoffa  frame,  in  which  the  patient  is  suspended  by  the  head, 
while  pads  are  run  in  from  the  sides  of  the  frame,  making  lateral  pres- 
sure in  various  directions. 

Correction  of  the  lateral  curve  of  the  spine  is,  however,  to  be  ob- 
tained most  economically  by  pressure  on  the  slack  spine,  which  is  most 
easily  secured  by  having  the  patient  lie  prone,  and  the  corrective  force 
should  be  divided  into  two  elements,  the  force  to  correct  the  rotation 
and  the  force  to  correct  the  side  deviation.  A  simple  apparatus  for 
this  is  as  follows  (Fig.  ii6): 

The  patient  lies  face  downward,  with  the  knees  flexed,  on  a  board  three  feet 
wide  by  four  feet  long.  Assuming  the  case  to  be  of  a  right  dorsal  curve,  a  broad 
canvas  strap  is  passed  around  the  left  upper  thorax,  over  and  under  the  patient,  and 
fastened  to  a  cleat  on  the  right  side  of  the  board.     This  furnishes  a  point  of  pressure 


146 


TREATMENT. 


to  the  left  against  the  upper  thorax  at  the  level  of  the  axilla.  A  broad  canvas  strap 
is  then  passed  around  the  pelvis  of  the  patient  above  and  below,  and  is  fastened  to  a 
cleat  at  the  right  side  of  the  board.  This  furnishes  a  point  of  pressure  to  the  left  at 
the  level  of  the  pelvis.  A  broad  canvas  strap  is  then  passed  around  the  thorax  at 
the  level  of  the  greatest  point  of  cur\-e;    it  passes  above  and  below  the  thorax  and  its 


Fig.  116. — Stretching    Board    with    Loops,    Ready    for    Application. — {"Jour.    Am. 

Med.  Assn.") 


Fig.  117. — Stretching  Board  with  Loops    Applied  to  .a  P.atient. — ("Jour.  Am.  Med. 

Assn.") 


upper  end  is  fastened  to  a  cleat  at  the  left  side  of  the  board  (Fig.  117).  Its  lower  end 
is  fastened  bv  means  of  a  string  into  a  compound  pulley  attached  to  a  cleat  at  the 
left  side  of  the  board.  By  means  of  this  pulley  any  reasonable  degree  of  force  may 
be  exerted  against  the  right  side  of  the  thorax,  pulling  it  to  the  left,  and  at  the  same 
time  that  it  piills,  it  tends  to  reduce  the  rotation  from  the  fact  that  its  upper  end  is 
fastened  and  its  lower  end  moving  toward  the  pulley. 


PASSIVE   STRETCHING. 


147 


A  better  and  much  more  efficient  appliance  has  been  made  by  Dr. 
Z.  B.  Adams,  of  Boston. 

In  this  a  patient  lies  prone,  with  the  knees  flexed,  on  a  table  which  is  split 
transversely  into  five  parts.  The  lower  one,  on  which  the  pelvis  rests,  is  furnished 
with  two  sliding  wooden  horns,  which  hold  the  pelvis  firm.  The  next  three  pieces 
are  provided  with  a  pad  sliding  in  from  the  side  and  a  pad  coming  down  from  the 
top.  These  three  movable  pieces  slide  from  side  to  side,  and  also  rotate  on  a  gas- 
pipe  running  the  length  of  the  table  longitudinally.     The  patient  is  placed  in  the 


Fig.  118. — Machine    for   Intermittent   Correction  Applied  to  a  Patient.- 

Am.  Med.  Assti.") 


-{"Jour. 


apparatus,  the  pads  are  adjusted  to  the  side  and  back  of  the  loin  or  thorax,  or  both, 
and,  by  side  pressure  and  a  twisting  of  each  arm,  both  rotation  and  lateral  deviation 
are  corrected  separately  at  each  level.  In  this  way  it  is  possible  to  correct  both  lat- 
eral deviation  and  rotation  at  one,  two,  or  three  levels  for  the  purposes  of  stretching 
the  spine  by  directly  applied  pressure.  The  top  part  of  the  table  farthest  aw^ay  from 
the  pelvis  of  the  patient  is  fixed  and  on  it  rest  the  arms  and  head. 

The  patients  are  stretched  daily  in  this  apparatus  and  left  in  the  corrected 
position  for  as  long  a  time  as  can  be  borne  comfortably — generallv  from  fifteen 
minutes  to  half  an  hour. 


148  TREATMENT. 

CONTINUOUS    STRETCHING    BY    MEANS    OF    PLASTER-OF-PARIS 
JACKETS  (FORCIBLE  CORRECTION). 

In  severe  cases  of  structural  lateral  curvature  no  means  of  treatment 
is  so  efficient  as  continuous  stretching  by  means  of  plaster  jackets  applied 
under  force.  This  method  is  spoken  of  as  "forcible  correction."  Such 
jackets  are  applied  in  the  hope  of  stretching  the  contracted  structures 
and  of  inducing  an  improvement  in  the  curve.  By  virtue  of  their  be- 
ing at  work  day  and  night  they  accomplish  much  better  results  than 
are  to  be  obtained  in  any  other  way. 

The  treatment  of  severe  scoliosis  by  plaster  jackets  applied  in  a 
corrected  position  is  not  new.  But  the  force  has  generally  been  applied 
to  the  spine  during  suspension.  Bradford  and  Brackett^  described  a 
frame  in  which  the  jacket  was  applied  as  the  patient  lay  prone,  but  even 
here  head  traction  was  used.  Nebel,^  Calot,^  Redard,"*  and  others  have 
used  the  horizontal  position. 

The  whole  question  was  given  a  new  impetus  by  Calot's  work  on 
the  forcible  correction  of  the  deformity  in  Pott's  disease  published  in 
1896.'^  The  later  tendency  has  been  toward  the  use  of  much  greater 
force  than  was  previously  employed. 

The  most  noteworthy  advance  in  the  forcible  corrective  treatment  of 
scoliosis  was  made  by  WuUstein,  who  has  applied  the  above-mentioned 
principles  with  force  and  precision  and  who  published  photographs 
showing  marked  improvement  in  patients  (Fig.  119).  His  method  is  to 
forcibly  extend  the  head  while  the  patient's  pelvis  is  strapped  to  a  seat 
which  can  be  tilted  to  make  the  pelvis  oblique  and  which  also  can  be 
rotated  to  change  the  relation  of  the  pelvis  to  the  spine.  Lateral  pres- 
sure is  made  by  pads  running  in  horizontally  from  the  sides  of  the  appa- 
ratus. By  a  combined  motion  of  the  seat  and  adjustable  pads  any 
degree  of  twist  of  the  spine  upon  the  pelvis  may  be  produced.  WuU- 
stein uses  a  large  amount  of  force  in  his  traction,  applying  up  to  250 
pounds  of  pull,  and  he  applies  a  plaster  jacket  while  the  patient  is  thus 
stretched  and  pushed  into  a  corrected  position.  This  jacket  embraces, 
as  must  all  such  jackets  to  be  wholly  efficient,  the  chest,  shoulders,  and 
head.  The  amount  of  force  required,  however,  is  excessive,  as  must 
be  the  case  where  force  is  not  economically  applied.     He  is  attempt- 

'  "Bos.  Med.  and  Surg.  Jour.,"  May  11,  1893;   Oct.  10,  1903. 

^  "Nebel:   "Zeitsch.  f.  orth.  Chir.,"  iv. 

^Calot:  XII  Internat.  med.  Kongress  zu  Moskau,  1897. 

^  Redard:   "Trans.  Amer.  Orth.  Assn.,"  xi,  447. 

^  Calot;   "France  Med.,"  1896,  52;   Schanz:    "Berl.  klin.  Wochens.,"    1902,  48 


FORCIBLE   CORRECTION. 


149 


ing  to  straighten  the  bent  stick  by  puUing  the  two  ends  apart,  and  when 
a  great  amount  of  force  has  thus  been  expended  in  stretching  the  spine, 
lateral  pressure  is  applied,  when  it  also  must  be  pushed  to  an  extreme 
on  account  of  the  stretching  of  the  spine  in  its  length. 


Fig.   119.— Patient   with    Plastfr    Jacket    Applied    in    Wl'i.i. stein's    Apparatus.— 

(irnllstrin.) 


In  some  experiments'  on  the  scoliotic  spine  of  a  cada\'er  the  following  points 
were  evident: 

There  was  in  the  spine  a  fixed  region,  bounded  above  and  below  by  the  most 
movable  parts  of  the  spine — the  lower  cervical  and  the  lower  dorsal  region.  Man- 
ipulations to  correct  either  the  rotation  or  the  lateral  curve  were,  therefore,  more 
likely  to  take  effect  above  and  below  the  curve  than  in  the  curve  itself.     Side  pres- 

*  R.  W.  Lovett:  "  Bost.  Med.  and  Surg.  Jour.,"  Oct.  31,  iqoi. 


^5° 


TREATMENT. 


sure  pushed  the  whole  dorsal  region  to  the  left,  but  made  little  impression  on  the 
curve  itself. 

This  contrast  between  the  fixed  and  movable  portions  was  notably  to  be  seen 
in  attempts  to  correct  the  rotation.  If  oblique  forward  pressure  were  made  upon 
the  angles  of  the  ribs,  as  prominent  on  the  right  side  of  the  back,  the  cage  of  the 
thorax  revolved  horizontally,  in  one  piece,  upon  the  two  movable  parts  above  and 
below  it,  and  the  lateral  curve,  as^seen  from  the  back,  was  increased.     This  was 


Fig.  120. — Patiknt  with  Right  Dorsal  Curve  with  Right  Side  of  Thorax  Carried 
Forward  and  the  Rotation  Improved  while  the  Lateral  Curve  is  Made 
More  Evident. 


because  the  curved  part  of  the  spine,  convex  to  the  right,  was  twisted  and  carried 
further  to  the  right,  and  the  convexity  of  the  lateral  curve  was  apparently  increased 
by  being  carried  into  another  plane,  thus  making  the  whole  lateral  curve  appear 
more  marked,  as  seen  from  the  back. 

The  reverse  of  this  manipulation  (that  is,  backward  side  pressure  upon  the 
right  side  of  the  chest)  increased  the  rotation,  but  diminished  the  lateral  de%dation 
of  the  spinous  processes  and  made  the  spine  straighter  when  \aewed  from  the  back. 


FORCIBLE   CORRECTION. 


151 


A  similar  experiment  was  made  upon  an  adult  woman  patient,  with  a  severe 
fixed  curve  similar  to  that  of  the  cadaver.  It  will  be  seen  that,  when  the  bony 
rotation  was  diminished  by  forward  pressure  on  the  angles  of  the  ribs  on  the  right 
side,  the  lateral  deviation  was  increased,  no  side  pressure  being  made.  When 
the  rotation  was  increased  by  backward  twisting  of  the  right  side,  on  the  other 
hand,  the  lateral  deviation  was  diminished  (Figs.  120  and  121). 

This  criticism  applies  not  only  to  the  use  of  much  corrective  apparatus,  but 


Fig.  121.— Same  Patient  with  the  Right   Side  of  the  Thorax   Carried  Backward 
AND  the  Rotation  Increased  but  the  Lateral  Curve  Made  Less  Evident. 


also  to  gymnastic  work  where  attempts  to  correct  the  rotation  in  fLxed  curves  is 
made  by  manual  pressure  upon  the  prominent  ribs. 

Forcible  correction  by  pure  side  pressure  may  increase  the  rotation,  but,  so 
far  as  it  is  effective,  will  diminish  the  lateral  deviation.  That  this  is  not  new  may 
be  appreciated  by  a  quotation  from  Schfeger^  in  1810:  "  Der  seitliche  Druck  auf 
die  Rippen  biege  diese  an  den  olmehin  scho?;  mehr  spitzen   Wivkein  noch  mehr 

'  Fischer,  quoted  by  Htissey. 


152 


TREATMENT. 


Spitzig  zu."  That  plaster  jackets  ma_v  cause  increase  of  the  rib  angles  is  demon- 
strated by  Hiissey.^  The  same  point,  that  plaster  jackets  may  increase  the  bony 
rotation  apparent  in  the  back,  has  been  alluded  to  by  Schulthess  and  \'ulpius.^ 

It  may,  therefore,  be  stated  that  attempts,  in  fixed  curves,  to  dimin- 
ish the  rotation  by  force  in  any  degree  directed  forward,  not  carefully 
antagonized,  will  lead  to  an  in- 
crease of  the  lateral  curve. 
Conversely,  attempts  to  dimin- 
ish the  lateral  curve,  by  pure 
lateral  pressure,  not  carefully 
antagonized,  will  result,  in  fixed 
curves,  in  an  increase  of  the 
rotation. 

The  solution  lies  in  dealing 


Fig.  122. — On  the  Left  is  a  Diagr.a.m 
Showing  a  Right  Dorsal  Left 
Lumbar  Curve. 

In  the  middle  diagram  the  curve  is  shown 
straightened  ;  on  the  right  the  curve 
has  been  pushed  over  to  the  left  un- 
changed. 


Fig.    123.— Patient    Thikti  i;n    \'ears    Old. 
Curv.xtlre    Due    to    Rickets;    Never 
Treated. 


separately  with  the  rotation  and  with  the  lateral  deviation.     Having 
corrected  the  lateral  deviation  first,  this  correction  is  held,  as  will  be 

^  Hiissey:    "Zeitsch.  f.  orth.  Chir.,"  viii,  2,  235. 
^Vulpius:    "Volkmann's  Samml.  klin.  \'ort.,"  276. 


FORCIBLE   CORRECTION. 


i53 
In  this  wav  one 


described,  while  the  rotation  is  corrected  or  vice  versa. 
element  is  not  improved  at  the  expense  of  the  other. 

Corrective  jackets  should  be  applied  to  the  patients  prone,  and 
preferably  with  the  legs  fie.xed,  as  this  diminishes  the  physiological  curves 
of  the  spine  and  further  simplifies  the  problem.  With  a  patient  thus 
lying  prone,  the  spine  is  in  the  most  favorable  condition  for  side  cor- 
rection, both  as  regards  side  deviation  and  rotation,  and  by  an  intelli- 


FiG.  124.— Patient  Lying  in  Correc- 
tive Frame,  Showing  the  Im- 
provement Gained  by  the  Hor- 
izontal Position. 

Photographed  from  above.    Patient  same 
as  in  Fig.  123. 


Fig.  125.  —  Patient  in  Corrective 
Frame  with  Side  Pressure  Ap- 
plied BY  Strap. 

Showing  additional  correction  to  that  in 
Fig.  124. 


gent  application  of  force  to  correct  each  of  these  elements  separately 
and  independently.     In  this  improved  position  the  jacket  is  applied. 

A  simple  application  of  this  method  is  to  be  found  by  having  the  patient  lie 
prone  in  a  rectangular  gas-pipe  frame  on  two  straps  of  webbing  running  from 
end  to  end,  cross  straps  supporting  the  pelvis  and  shoulders.  By  means  of  webbing 
straps  attached  to  the  side  of  the  frame,  in  a  right  dorsal  curve,  one  going  around 
the  left  side  of  the  pelvis  and  another  around  the  left  upper  thorax,  while  a  third 
pulls  on  the  right  side  of  the  thorax  against  these  as  points  of  resistance,  great 


154 


TREATMENT. 


improvement  in  the  position  may  be  obtained,  which  is  secured  by  the  application 
of  a  plaster  jacket,  but  the  apparatus  is  deficient  because  it  corrects  chiefly  the 
side  deviation  and  makes  but  little  pro\dsion  for  the  correction  of  rotation,  which 
must  be  largely  done  by  the  hands. 

The  problem  of  the  appHcation  of  plaster  jackets  on  this  plan  hav- 
ing thus  presented  itself  was  worked  out  mechanically  by  Dr.  Z.  B. 
Adams,  of  Boston. 

The  apparatus  consists^of  a  heavy  gas-pipe  frame,  three  by  four  feet.  The 
patient  lies  face  downward  on  two  webbing  strips  running  from  end  to  end  of  the 


Fig.  126. — App.\ratus  for   Forcible  Correction   bv  Plaster  Jackets. — {''Jour. 

Med.  Assn.'") 


fi:ame  with  the  legs  flexed.  Near  the  bottom  of  the  frame  is  an  adjustable  cross- 
bar bent  to  fit  into  the  flexure  between  the  thigh  and  the  pelvis  on  which  the  patient 
rests  the  lower  part  of  the  body.  Sliding  on  this  bar  are  two  arms,  which  slide 
in  and  clamp  down  on  the  buttocks,  holding  the  pelvis  steady  on  the  cross-bar. 
This  bar  is  movable  from  side  to  side  in  order  to  induce  or  correct  curvature  in  the 
lumbar  region  when  necessary.  There  are  three  vertical  transverse  rings,  two 
feet  in  diameter,  fastened  to  pieces  on  the  sides  of  the  frame  so  that  they  can  be 
moved  to  any  desired  point  along  the  frame.  These  rings  are  also  movable  from 
side  to  side,  and  by  an  independent  movement  they  can  also  be  rotated  through 
a  half  circle.  Any  one  of  these  movements  can  be  checked  at  any  point  by  turning 
a  screw.  The  shoulders  are  held  by  a  pair  of  axillary  straps  fastened  together  by 
a  strap  across  the  chest  in  front.  These  straps  are  suspended  from  the  ring  nearest 
to  the  top  of  the  frame,  and  can  be  made  to  hold  the  shoulders  in  any  desired  degree 
of  twist  by  a  rotation  of  the  ring. 

Each  ring  is  provided  with  two  long  rods  at  the  two  poles  of  the  ring.  These 
rods  are  adjustable  on  the  ring,  and  can  be  set  at  any  desired  angle  to  it.  They 
can  be  pushed  up  or  down  and  are  controlled  by  a  ratchet.     By  rotating  the  ring 


FORCIBLE   CORRECTION. 


155 


and  adjusting  the  angle  of  the  rods  they  can  be  made  to  press  down  or  up  on  any 
part  of  the  back  or  chest. 

For  the  application  of  the  jacket  the  patient  lies  on  the  face  on  the  two  web- 
bing strips,  the  lower  part  of  the  trunk  resting  on  the  cross-rod  and  the  bars  clamping 


i) 


the  buttocks;  the  feet  rest  on  the  floor,  and  the  arms  are  extended  above  the  head. 
The  rings  are  then  adjusted  at  the  two  levels  where  it  is  desired  to  make  correction. 
For  side  correction  a  bandage  is  fastened  to  one  side  of  the  ring,  carried  around 
the  patient's  side  over  a  heavy  pad  of  felt,  and  back  to  the  ring.  The  same  is 
done  to  the  other  ring  at  the  other  level  where  side  correction  is  desired,  while  the 


156 


TREATMENT. 


top  ring  controls  the  shoulders  by  means  of  the  pads  and  two  loops  of  bandages 
passing  through  each  axilla  and  fastened  to  the  top  of  the  ring.  The  rings  are 
then  pulled  to  one  side,  the  bandages  around  the  patient  tighten,  and  any  endurable 
degree  of  side  correction  is  thus  obtained. 

When  the  side  correction  is  made,  the  ring  is  rotated  till  the  rods  are  opposite 
the  points  where  it  is  desired  to  correct  rotation.  They  are  then  pushed  down 
on  to  the  patient,  their  points  being  protected  by  sheet-iron  pads,  two  by  three 
inches,  which  are  covered  with  heavy  felt.  These  pads  are  incorporated  in  the 
jacket. 

A  plaster  jacket  is  applied  to  the  patient  held  in  this  way.     It  is  easy  to  see 


-Patient   of   Whom  Radiograms  were  taken,  before  Treatment. 
.■^RY,  1906.) — {"■  Jo7ir.  Am.  Med.  Assn.") 


(JANU- 


that  the  method  is  perfectly  definite  and  that  the  amount  of  force  at  the  operator's 
disposal  is  very  great. 

Technic  of  Application. — The  patient  should  preferably  be  stretched  once 
or  twice  daily  for  two  or  three  days  preliminary  to  the  correction  in  the  machine 
in  which  the  jacket  is  to  be  applied,  but  this  is  not  essential.  Anesthesia  is  never 
necessary,  as  all  endurable  correction  may  be  obtained  without  much  pain.  A 
seamless  undervest  is  put  on  and  the  iliac  crests  padded  with  hea^'y  felt;  a  pad 
should  also  be  placed  over  the  sacrum.  Under  the  side  straps  heavy  felt  pads 
are  required. 

The  correction  is  pushed  to  the  point  of  causing  mild  discomfort,  and  difficulty 


FORCIBLE    CORRECTION. 


157 


in  breathing  is  a  sign  of  too  much  correction.  The  amount  to  be  obtained  in  any 
case  is  better  decided  by  the  patient's  sensations  than  by  any  theoretical  standard. 
The  danger  lies  on  the  side  of  obtaining  too  much  rather  than  too  little  correction, 
for  the  jacket  will  be  much  more  uncomfortable  when  the  erect  position  is  assumed. 
After  the  patient  has  been  removed  from  the  apparatus  the  shoulders  are  incor- 
porated in  the  jacket. 

After  correction  the  patient  should  remain  in  a  hospital  or  under  close  obser- 
vation for  at  least  twenty-four  hours.     Some  shock  is  not  infrequently  experienced 


Fig.  129.— Patient  Shown  in  Fig.  12S  after  Wearing  Corrective  Jack;et  for   over 
A  Year.    (March,  1907.) 


and  in  a  case  of  the  writer's  very  serious  collapse  and  cyanosis  followed  the  cor- 
rection of  a  severe  curve  due  to  infantile  paralysis  in  a  child  of  six.  Wullstein  has 
recorded  the  occurrence  of  somewhat  serious  symptoms  following  correction. 

Successful  permanent  results  can  be  obtained  in  hospital  practice  in 
only  selected  cases,  the  average  patient  being  unable  to  appreciate 
the  importance  of  following  out  the  after-treatment.  The  most  favora- 
ble cases  for  forcible  correction  are  curves  affecting  the  lower  dorsal 
and  dorsolumbar  regions.  Lumbar  curves  are  not  accessible  to  side 
pressure,  and  high  dorsal  curves  are  resistant  because  one  cannot  ob- 
tain a  counterpoint  higher  than  the  axilla,  which  is  not  far  above  the 


158 


TREATMENT. 


center  of  the  curve.  Such  cases  are  to  be  corrected,  if  at  all,  by  jackets 
applied  in  suspension  by  the  head  by  a  Sayre  sling.  Curves  due  to 
infantile  paralysis,  rickets,  and  empyema  are  available  for  forcible 
correction. 

Permanence  of  Results. — The  criticism  that  such  correction  is  not 


Fig.  130.— Radiogram  of  a  Patient  Seventeen  Years  Old  (Fig.  128)  Lying  on  the 
Back,  before  the  Application  of  Jacket.  (January,  1906.) — {"Jotir.  Atn.  Med. 
Assn.") 


likely  to  be  permanent  at  once  presents  itself.  The  grounds  that  lead 
one  to  suppose  that  retention  of  the  growing  spine  in  a  corrected  posi- 
tion over  a  sufficient  period  w'Al  lead  to  a  change  in  the  shape  of  the 
bones  of  the  vertebral  column  and  to  a  permanently  improved  position 
are  as  follows : 

(i)  Club-foot  may  be  cured  by  a  similar  proceeding. 


FORCIBLE   CORRECTION.  1 59 

(2)  The  bones  of  the  feet  of  Chinese  women  of  rank  are  seriously 
misshapen  by  retention  in  an  unnatural  position.^ 

(3)  Wullstein  produced  bony  changes  in  dogs  by  a  few  months  of 
abnormal  position. 

(4)  W.  Arbuthnot  Lane"  has  demonstrated  that   the   carrying   of 


Fig.  131.— Radiogram  of  Same  Patient  as  shown  in  Fig.  128,  Taken  after  the  Ap- 
plication OF  a  Plaster  Jacket  through  Windows  Cut  in  Front  and  Back  of 
Jacket.     (January,  igo6.) — {''Jour.  Am.  Med.  Assn.") 


heavy  loads  by  laborers  will  produce  changes  in  the  bony  skeleton  and 

that  the  changes  vary  according  to  the  habitual  position  of  the  load, 

the  bones  subject  to  the  greatest  pressure  undergoing  changes  in  shape. 

(5)  The  fact  that  bone  under  pressure  changes  shape  after  growth 

^  P.  Brown:    "Jour.  Med.  Research,"  Dec,  1903. 
^  Guy's  Hosp.  Rep.,  xxviii. 


i6o 


TREATMENT. 


has  been  reached  is  shown  in  the  fact  that  scar  tissue  pressing  on  bone 

will  cause  a  change  in  shape/  e.  g.,  on  the  chin. 

(6)  Pressure  of  tumors  or  aneurysm  will  cause  absorption  of  bone- 
These  facts  all  point  to   the  conclusion  that  bone  alters  its  shape 

under  changed  conditions  of  pressure,  and  that  although  this  would 


Fig.  132.- 


-Radiogram   of   Patient   Shown   in   Fig.  12S  aftkr    Wearisg   Corrective 
Jacket  for  over  One  Year.     (March,  1907.) 


be  more  marked  during  growth,  the  phenomenon  is  not  unknown  in 
adult  life. 

That  a  practical  gain  in  the  curved  part  of  the  spine  may  be  secured 
by  this  method  is  demonstrated  by  the  .v-rays  shown  in  the  illustra- 
tions. The  patient  was  a  girl  of  seventeen,  with  a  severe  right 
dorsal  curve,  which  was  extremely  rigid  and  had  never  been  treated. 
The  first  x-ray  was  taken  with  the  patient  lying  on  the  back.  A  correc- 
tive jacket  was  applied  in  the  Adams  apparatus,  the  front  and  back  of 

^Ziegler;    Pathology,  English  ed.,   1S96,  ii,   146. 


FORCIBLE   CORRECTION. 


l6l 


the  jacket  were  cut  away  to  permit  another  .r-ray,  and  the  improvement 
in  position  is  evident.  It  seems  reasonable  to  hope  that  the  mainte- 
nance of  such  an  improved  position  may  be  expected  in  time  to  produce 
a  change  in  the  shape  of  the  vertebrae.  It  is  obvious  that  such  a  cor- 
rected position  must  be  maintained  over  a  period  of  many  months  to 
secure  permanent  results.  As  a  rule,  the  first  corrective  jacket  does 
not  secure  the  maximum  correction,  and  a  second  or  even  third  correc- 
tive jacket  should  be  applied  if  there  is  reason  to  suppose  that  there  is 


133. — Patient    Seventeen    Years    Old,    Never    Previously    Treated,  Before 
Treatment. — {''Jour.  Am.  Med.  Assti.") 


further  gain  to  be  obtained.     An  interval  of  one  or  two  weeks  between 
the  jackets  is  sufficient  (Figs.  130-132). 

When  this  final  jacket  has  been  applied,  there  are  two  methods  of 
procedure,  (i)  The  final  jacket  may  be  removed,  and  one  holding 
an  equally  good  positicn  may  be  applied  after  a  month  or  more  from  the 
forcible  correction  (see  Braces  and  Corsets).  This  jacket  is  worn  night 
and  day,  and  is  to  be  removed  only  during  the  exercise  periods,  gym- 
nastic treatment  having  been  commenced  when  the  final  jacket  is  re- 


l62 


TREATMENT. 


moved,  (2)  In  the  second  method  of  procedure  the  final  corrective 
jacket  is  worn  for  a  year  or  more  without  being  split,  with  a  view  to 
conforming  the  child's  figure  to  the  shape  of  the  jacket,  just  as  a  club- 
foot is  made  to  grow  straight  in  a  corrective  plaster  splint  and  as  the 
Chinese  girl's  foot  is  shaped  by  continuous  bandaging  (Figs.  128  and  129). 
The  choice  between  these  methods  must  be  determined  by  the 
circumstances  of  the  patient,  the  temperament  of  the  child,  and  simi- 
lar considerations.     Careless  hospital  patients  will  do  better  in  a  fixed 


Fig.  134. — Same  Patient  as  in  Fig.  133,  after  Two  Jackets.    Whole  Interval,  Three 
Weeks. —  {^^  Jour.  Am.  Med.  Assti.") 


jacket  for  a  year  or  two,  while  nervous  girls  in  private  practice  will  do 
better  in  split  jackets. 

Schanz  has  provided  clinical  evidence  of  the  permanence  of  results 
in  a  series  of  cases  reported  by  photograph,^  and  presents  his  conclu- 
sion, which  expresses  thoroughly  the  views  of  the  writer,  as  follows: 

"That  one  by  a  careful  selection  of  cases  and  correct  carrying 
through  of  the  necessary  measures  can  retain  the  results  of  forcible 

*  "Verhandl.  d.  Deutsch.  Ges.  f.  orth.  Chin,"  4.  Congress,  page  61. 


BRACES   AND   CORSETS.  163 

correction  of  scoliosis  and  permanently  avoid  the  danger  of  relapse, 
my  experience  of  over  eight  years  with  the  method  has  proved  beyond 
doubt." 

It  is  undesirable  to  undertake  forcible  correction  unless  the  patient 
can  be  under  control  for  a  period  of  two  years  at  least. 

Gymnastics  Following  Forcible  Correction. — So  soon  as  the 
final  corrective  jacket  has  been  removed  and  replaced  by  a  removable 
one,  gymnastic  treatment  should  be  begun.  The  exercises  to  be  used 
have  been  described  in  the  section  on  Gymnastics.  Such  treatment 
to  accomplish  results  must  be  given  from  one  to  four  hours  a  day  for 
a  period  of  at  least  six  months  from  the  removal  of  the  final  corrective 
jacket,  after  which  less  frequent  and  vigorous  exercises  may  be  suffi- 
cient. Exercises  must  be  continued  until  the  corrected  position  is 
maintained  without  apparatus  from  month  to  month,  and  the  support- 
ing apparatus  discontinued  at  first  for  short  periods,  gradually  increas- 
ing in  length.  The  length  of  time  that  active  treatment  must  be  con- 
tinued will  depend  on  the  age  of  the  child,  the  severity  of  the  case,  the 
efficiency  of  the  treatment,  and  similar  factors,  but  any  case  of  sco- 
liosis severe  enough  to  require  forcible  correction  will  not,  as  a  rule, 
occupy  less  than  two  years,  and  often  a  longer  period. 

The  present  discredit  of  gymnastic  retentive  treatment  is  due  to  its 
use  in  too  small  dosage  and  to  a  failure  to  appreciate  that  a  problem  so 
grave  as  the  permanent  maintenance  of  the  corrected  position  in  a 
spine,  which  has  suffered  some  degree  of  bony  distortion,  is  only  to  be 
obtained  by  a  long  continuance  of  accurate  and  mechanically  sound 
treatment. 

BRACES  AND  CORSETS. 
Braces  and  corsets  of  themselves  have  no  place  in  the  corrective 
treatment  of  lateral  curvature,  and  are  only  to  be  regarded  as  a  means 
of  retaining  the  gain  secured  by  other  methods.  They  must  be  regarded 
as  having  in  themselves  no  corrective  value,  for  such  apparatus  applied 
to  a  spine  not  previously  loosened  up  by  treatment  is  not  able  to  secure 
any  considerable  correction  by  pressure  on  the  spine  because  the  base 
for  the  leverage  to  be  obtained  from  the  pelvis  must  consist  in  a  pres- 
sure obtained  from  the  space  between  the  crest  of  the  ilium  and  the 
top  of  the  trochanter.  Direct  pressure  on  the  crest  of  the  ilium  is  not 
tolerated,  and  pressure  on  the  trochanter  interferes  with  walking  and 
sitting.  It  is  manifestly  impracticable  from  this  small  space  to  obtain 
a  hold  which  will  exercise  a  sufficient  side  thrust  on  the  thorax  to  be 
corrective.     The  current  practice  of  the  instrument-makers  of  fitting 


164 


TREATMENT. 


corsets  and  braces  to  such  patients  and  allowing  the  parents  to  hope 
for  any  considerable  benefit  is  therefore  to  be  condemned. 

The  most  easily  made  and  available  corset  is  to  be  manufactured 
by  removing  from  the  patient  the  last  corrective  jacket,  filling  it  with 
plaster-of-Paris  and  water,  thus  securing  a  torso  of  the  patient.  This 
torso  is  then  further  corrected  by  cutting  away  the  plaster  on  the  convex 
side  and  by  building  up  on  the  concave  side  so  as  to  secure  a  symmetrical 
or  over  corrected  model  on  which  a  jacket  may  be  applied,  or  the  pa- 
tient may  be  suspended  by  a  Sayre  sling  and  a  jacket  applied  and  cut 
off  to  serve  as  a  model  for  a  torso.  The  torso  is  then  shellacked  and 
covered  with  a  layer  of  stockinet  or  an  undershirt,  and  a  plaster  jacket, 
having  been  applied  on  the  torso,  is  cut  off,  furnished  with  lacings. 


Fig.  135. — On  the  Left  is  a  Plaster  Torso  Made  from  a  Corrective  Jacket. 
On  the  Right  is  the  Same  Torso  Made  More  Symmetrical  for  the  Applica- 
tion OF  A  Removable  Jacket. 


and  suppHed  to  the  patient.  All  plaster  jackets  applied  for  forcible 
correction  and  retention  must  embrace  the  shoulders,  and  even  the 
head  should  be  included,  but  the  disfigurement  is  so  great  that  most 
patients  are  unwilling  to  submit  to  it  in  America.  On  the  torso  obtained 
as  described  may  be  constructed  jackets  of  celluloid,  leather,  or  other 
material,  or  corsets  made  of  cloth  and  reinforced  by  steel. 

The  writer  has  found  a  segmented  jacket  of  more  general  use  than 
the  ordinary  one.  A  jacket  is  applied  on  a  plaster  torso  in  the  usual 
way,  and  then  the  upper  section,  corresponding  to  the  thorax,  is  sepa- 
rated from  the  rest  of  the  jacket  by  a  transverse  cut.  The  lower  sec- 
tion, corresponding  to  the  pelvis,  is  separated  in  a  similar  way,  and  the 
two  sections  are  then  set  in  any  desired  relation  to  each  other  by  means 


BRACES    AND   CORSETS. 


165 


of  three  steel  strips,  running  vertically  at  the  back  and  sides  of  the  jacket, 
connecting  the  two  sections.  The  thorax  may  thus  be  lifted  in  relation 
to  the  pelvis,  displaced  to  either  side,  or  rotated  in  relation  to  the  pel- 
vis, or  any  combination  of  these  may  be  brought  about.  As  treat- 
ment progresses  the  gain  may  be  secured  by  changed  relations  of  tho- 
racic and  pelvic  sections  (Fig.  136).  The  shoulders  are  controlled  by 
pads  pressing  on  the  anterior  aspect  of  the  shoulder-joints. 


Fig.  136.— Segmented  Corrective  Plaster  J.acket. 


The  complicated  braces  in  former  use  have  been  largely  displaced 
by  the  jacket  or  corset.  They  may  be  found  described  in  the  refer- 
ences.^ The  corset  used  in  Germany  is  shown  in  the  illustration  (Fig. 
137).  The  brace  devised  by  C.  W.  Keene,  of  Boston,  is  efficient  and 
may  be  taken  as  an  example  of  the  type  of  modern  brace  (Fig.  138). 

Operation. — The  question  of  the  operative  relief  of  scoliosis  is  still 
snhjudice.     An  operation  was  proposed  by  Volkmann-  in  1889,  consist- 

^Hoffa:  "Lehrb.  d.  orth.  Chir.,"  fourth  ed.,  1Q05,  page42Q;  Redard:  "Chirurgie 
Orthopedique,"  Paris,  i8q2,  page  382;  Bradford  and  Lovett:  "Orth.  Surg.," 
first  ed.,  iSqo,  page  16S. 

^Volkmann:    "Bcrl.  klin.  Wochens.,"  18S0,  50. 


i66 


TREATMENT. 


ing  of  resection  of  the  ribs  on  the  convex  side  of  the  curve,  and  this 
operation  was  also  performed  by  Casse^  and  Hoffa^  with  fair  results. 
A  similar  operation  was  thought  out  by  N.  M.  Shaffer,  of  New  York, 
about  fifteen  years  ago,  and  spoken  of  to  the  writer  at  that  time  but 
never  put  on  record,  as  the  general  surgeons  to  whom  it  was  referred 
refused  to  sanction  it.^ 

A  good  operative  correction  has  been  obtained  by  Hoke,*  of  Atlanta, 
Ga.,  who  resected  the  ribs  on  the  convex  side  of  a  girl  of  nineteen  and 


Fig.    137.  —  Corset    for    Scoliosis 
Strengthened  by  Steel.— (Z^o- 


FiG.  138. — Brace  for  a  Case  of  Right 
Dorsal  Scoliosis,  Applied. — {C. 
IV.  Keene.) 


lengthened  those  of  the  concave  side  in  a  severe  dorsal  curve.     By  the 
application  of  a  corrective  jacket  great  improvement  was  obtained. 

Jaboulay^  divided  the  cartilage  of  a  single  rib  with  a  view  of  im- 
proving the  shape  of  the  thorax.  Bade®  has  reported  a  case  where  he 
resected  the  ribs,  but  cautions  against  the  use  of  narcosis  in  severe  sco- 
liosis. 

^  Casse:  "Bull,  de  I'Acad.  Royal  de  Med.  de  Belgique,"  Dec.  30,  1893;  Jan. 
27,  1894. 

^Hoffa:    "Zeitsch.  f.  orth.  Chir.,"  1896,  401. 

^  Shaffer:    "Amer.  Surg.  Bulletin,"  Jan.   i,   1894. 

*Hoke:    "Amer.  Jour,  of  Orth.  Surg.,"  i,  2. 

^Jaboulay:    "Prog.   Med.,"   Nov.,    1893. 

'  Bade:  "Klin.  Mittheil.  in  Centralbl.  f.  Chir.,"  1903,  38,  1045. 


Chapter  XII. 

FAULTY  ATTITUDE. 

The  investigation  of  the  types  of  faulty  attitude  must  be  preceded  by 
a  consideration  of  the  normal  attitude  in  the  anteroposterior  plane. 

NORMAL  ATTITUDE. 

Normals  have  been  described  by  Weber/  Meyer/  Danger/  Parou/ 
Henke/  Staffel/  and  others/  which  differ  much  among  themselves,  as 
would  have  been  expected  from  the  lack  of  a  uniform  system  of  measure- 
ment and  because  the  normal  type  of  standing  is  affected  by  age,  sex, 
race,  fashion,  and  occupation.  A  military  cadet  would  not  be  expected 
to  present  the  same  normal  as  a  woman  of  the  same  age  who  had  worn 
tight  clothes,  heavy  skirts,  and  pointed  boots  for  some  years. 

One  simple  relation  seems  fairly  constant  above  ten  or  twelve.  A 
plumb-line  held  against  the  back  of  the  sacrum  touches  or  comes  near 
the  convexity  of  the  dorsal  spine.  In  young  children  it  cuts  this  con- 
vexity. Slack  standing  makes  the  dorsal  spine  more  prominent  back- 
ward, and  the  dorsal  curve  lies  in  part  back  of  this  line  under  these  con- 
ditions. 

In  order  to  approach  the  subject  of  normal  attitude  and  the  varia- 
tions from  it  with  some  hope  of  solution  a  method  of  analysis  and  mea- 
surement was  devised  which  has  proved  satisfactory. 

Former  observations  have  been  concerned  mostly  with  the  spinal 
curve  alone,  but  to  appreciate  the  affection  properly  the  base  of  support 
must  also  be  considered.  This  method  of  record  throws  a  certain 
practical  light  upon  the  question  of  treatment. 

The  apparatus  by  which  the  measurements  are  taken  consists  of  the 
ordinary  wooden  upright  with  a  sliding  arm  used  for  measuring  the  height. 

*  "Mechanik  der  mensch.  Gehwerkzeuge." 
'"Ueber  den  Mech.  des  mensch.  Ganges,"  1885. 

'"•  Langer  and  H.  Meyer:  "Anat.  der  ausseren  Formen  d.  mensch.  Korpers." 

*  Parou:  "Virchow's  Arch.,"  1864,  xxxi,  1-2. 

^  Henke:  "Anat.  u.  Mech.  der  Gelenke,"  p.  213. 

'Franz  Staffel:  "Die  menschl.  Haltungstypen,"  etc.,  Wiesbaden,  1889. 
^  Froriep:  "Anat.  f.  Kiinstler,"  Leipzig,  18S0,  p.  40. 

167 


i68 


FAULTY   ATTITUDE. 


On  this  sliding  arm  and  at  right  angles  to  it  is  a  horizontal  arm  eighteen 
inches  long,  which  is  placed  six  inches  from  the  back  surface  of  the  ujj- 
right  rod.     This  back  surface  of  the  upright  rod  is  taken  as  the  per])en- 


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3lII 

Fig.  139. — Apparatus  for  Measuring  \'aria- 
TioNS  FROM  Normal  Attitude  in  the 
Anteroposterior  Plane. 


Fig.  140.— Graphic  Representation 
OF  Standing  Position,  with  the 
Patient  Faced  to  TfiE  Left. 


NORMAL   ATTITUnE.  1 69 

dicular  plane  from  which  distances  are  to  be  noted,  and  the  measure- 
ments are  made  from  the  shding  horizontal  arm,  which  is  always  six 
inches  distant  from  the  back  surface  of  the  upright.  Any  point,  therefore, 
more  than  six  inches  from  the  sliding  horizontal  arm  is  in  front  of  the 
perpendicular  plane  agreed  on,  and  any  point  less  than  six  inches  is 
behind  it  (Fig.  139). 

The  middle  of  the  external  malleolus  was  taken  as  the  lower  end  of 
the  perpendicvdar  plane  from  which  measurements  were  to  be  made. 
The  patient  stands  without  boots,  in  a  natural  position,  with  the  feet 
forming  an  angle  of  45  degrees,  and  with  the  middle  of  one  malleolus 
opposite  the  back  surface  of  the  upright,  the  back  of  the  patient  being 
toward  the  sliding  horizontal  arm. 

The  measurements  of  the  bony  landmarks  to  be  mentioned  are  then 
taken  from  the  sliding  horizontal  arm,  and  the  height  at  which  each 
measurement  is  taken  is  recorded.  This  may  be  done,  of  course,  either 
in  inches  or  centimeters.  Having  then  the  height  of  each  point  desired 
as  well  as  its  distance  from  the  ground,  it  is  a  simple  matter  to  pro- 
duce graphically  the  relation  of  these  points  by  using  ordinary  coordi- 
nate paper  and  allowing  one  inch  or  one  centimeter  to  each  space  on  the 
paper.  To  secure  uniformity  of  results,  it  may  be  assumed  that  the 
patient  is  seen  facing  the  left. 

The  landmarks  taken  for  measurement  were  those  which  could  be 
easily  identified  by  touch.  They  are  as  follows  from  above  downward: 
(i)  The  middle  of  the  mastoid  process;  (2)  the  spine  of  the  vertebra 
prominens;  (3)  the  spine  of  the  seventh  dorsal  vertebra  (on  a  level  with 
the  inferior  angle  of  the  scapula) ;  (4)  the  spine  of  the  fourth  lumbar 
vertebra  (on  a  level  with  the  top  of  the  iliac  crest) ;  (5)  the  middle  of 
the  great  trochanter;  (6)  the  middle  of  the  head  of  the  fibula ;  (7)  the 
middle  of  the  external  malleolus. 

The  measurement  is  taken  by  marking  with  a  skin  pencil  the  points 
to  be  measured.  The  patient  is  then  placed  with  the  back  to  the  slid- 
ing arm  and  the  outer  malleoli  opposite  the  back  edge  of  the  upright. 
In  order  to  get  the  measurements  before  the  patient  becomes  fatigued 
and  sways,  it  is  necessary  to  work  quickly.  The  mastoid  measure  is 
taken,  and  then  the  arm  pushed  rapidly  down  while  the  distances  of 
the  points  from  it  are  measured  with  a  rule  at  each  level.  Having 
taken  these  down,  it  is  necessary,  if  the  curve  is  to  be  reproduced 
graphicallv,  to  record  the  height  from  the  ground  of  each  bony  land- 
mark, and  the  sliding  arm  is  again  pushed  up  and  the  level  of  each 
marked  bonv  landmark  recorded.     B\-  this  division  of  the  two  measures 


I  7©  FAULTY   ATTITUDE. 

the  first  and  important  one  should  be  finished  before  the  patient  be- 
comes unsteady,  and  in  the  second  set  swaying  is  of  no  account. 
A  typical  measurement  would  be  as  follows: 

Case  M.  L.     T\-pe  a. 

Distance  from  Upright.  Height. 

Mastoid yf  inches.  49    inches. 


Seventh  cervical 5^ 

Seventh  dorsal 4^ 

Fourth  lumbar 5^ 

Trochanter 7  J 

Head  of  fibula 7! 

Malleolus 6 


46i 
40 

I4i 

2i 


The  curve  is  plotted  by  marking  the  points  on  coordinate  paper  and 
drawing  lines  between  them.  As  below  the  level  of  the  fourth  lumbar 
vertebra  the  line  no  longer  follows  the  back  outline  of  the  body,  but 
changes  to  the  axis  of  the  leg;  the  fourth  lumbar  and  trochanter  marks 
are  not  connected  by  a  line. 

The  method  has  been  repeatedly  tested  by  taking  two  successive 
independent  measurements  of  the  same  patient  and  comparing  them, 
and  by  taking  measurements  on  succeeding  days  and  comparing  them, 
with  the  result  of  finding  that  the  two  conformed  on  the  whole,  the  type 
persisting  and  the  chief  difference  being  in  slight  swaying  forward  or 
back  which  was  at  times  evident. 

The  method  is  not  intended  to  be  mathematically  accurate,  but  to 
give  a  fairly  accurate  graphic  representation  of  the  patient's  method  of 
standing.  It  has  the  advantage  of  being  applicable  in  adults,  where 
record  by  full-length  phocographs  is  not  available,  and  the  measure- 
ments can  obviously  be  taken  without  objectionable  exposure  in  the  case 
of  women. 

The  measurements  of  seventy-two  normal  boys  between  the  ages  of 
fifteen  and  nineteen,  taken  by  Dr.  Greenwood,  seem  the  material  most 
available  to  compare  with  the  normals  described.  They  were  all  healthy, 
well-developed  boys,  averaging  eighteen  years  of  age,  and  the  individual 
tracings  differed  but  little  from  each  other.  An  average  curve  of  the 
tracings  is,  therefore,  representative  of  the  standing  position  of  these 
young  men  (Fig.  141). 

Tracings  of  the  curves  of  the  normal  attitudes  as  represented  by 
v.  Meyer,  Langer,  and  Stafi'elwere  then  taken  by  marking  on  then:  figures 
the  places  of  the  bony  landmarks  adopted,  connecting  them  with  lines 
and  considering  them  in  their  relation  to  a  perpendicular  erected  through 
the  external  malleolus  in  each  case.  The  normal  of  v.  ]\Ieyer  repro- 
duced in  that  way  was  unlike  any  curve  found  in  normal  persons,  while 
that  of  Langer  is  also  unusual.     The  normal  curve  constructed  from 


NORMAL   ATTITUDE. 


171 


StaffePs   figure   is,   however,    practically    identical   with    that    of  the 
seventy-two  boys. 

With  regard  to  the  cur\es  of  six  hundred  college  girls,  taken  by  the 


Fig.   141.  — Composite  Fig.    142.— Staf-       Fig.  143.— Langer's      Fig.  144.— v.  Meyer's 

Curve  of  Seventy-  pel's  Normal.                  Normal.                           Normal. 
TWO   Normal  Boys. 
—  (Greenwood. ) 

physical  examiner  of  the  college,  the  individual  variations  are  much 
greater  than  in  the  males,  and  there  is  a  general  tendency  to  carry  the 


172 


FAULTY   ATTITUDE. 


body  further  forward  and  to  hyperextend  the  knees,  the  lumbar  curve, 

also,  as  one  would  expect,  being  greater 
I  than  in  the  males  (Fig.  148). 

Types  of  Variation  in  Faulty  Atti- 
tude.— As  no  one  classification  of  these 
types  has  been  universally  adopted,  and 
as  the  classifications  difi'er  among  them- 
selves, it  seemed  best  to  start  afresh 


Fig.  145. — Type 
A  OF  Round 
Shoulders. 


Fig.  146. — Type 
B  OF  Round 
Shoulders. 


Fig.  147. —Type  C 
of  Round  Shoul- 
ders. 


Fig.  148.— Curve  of 
Young  Adult 
Fkm.'I.le  of  Good 
Carri.age. 


VARIATIONS    FROM    NORMAL   ATTITUDE.  1 73 

and  see  if  these  measurements  of  patients  (mostly  children)  offered  any 
basis  of  reasonable  classification  by  which  they  might  be  divided  into 
groups  for  study,  to  see  what  constant  types  of  variation  the  curves 
showed,  and  to  find  out  by  photographs  to  what  clinical  types  of  faulty 
attitude  these  variations  corresponded. 

It  was  difficult  to  decide  what  factor  in  the  attitude  should  be  the 
basis  for  classification;  whether  it  should  be  the  relation  of  the  trunk 
to  the  legs,  of  the  pelvis  to  the  perpendicular,  of  the  whole  swing  of  the 
body  backward  or  forward,  or  of  the  relation  of  the  points  in  the  spine 
itself.  On  examining  the  graphic  representations  of  the  tracings  of 
fauljy  attitude  in  this  connection  the  most  constant  grouping  seemed  to 
be  by  the  spinal  curve.  That  is,  the  cases  showed  four  types  of  spinal 
curves,  and,  arranged  according  to  these  types,  the  other  characteris- 
tics of  the  curves  seemed  to  be  fairly  constant  in  each  group. 

The  four  types  of  spinal  curve  were  as  follows: 

Type  A. — A  general  curve  (an  exaggeration  of  the  normal  lines), 
where  the  spine  from  the  mastoid  to  the  fourth  lumbar  forms  one  gen- 
eral curve  backward.  As  a  rule,  there  is  little  lordosis  in  these  cases  (as 
shown  by  the  relation  of  the  fourth  lumbar  to  the  trochanter).  The 
pelvis  is,  as  a  rule,  well  in  front  of  the  perpendicular,  and  the  body  axis 
lies  generally  in  the  perpendicular,  but  may  be  wholly  in  front  of  it,  and 
in  one  case  only  lay  behind  it.  The  legs,  as  a  rule,  incline  forward,  and 
are  rarely  hyperextended  at  the  knee.  This  is  the  most  frequent  type, 
and  consists,  in  a  word,  of  rounded  back  with  little  forward  lumbar 
curve  (Fig.  145). 

Type  B. — Backward  projection  greatest  in  the  mid-dorsal  region, 
the  seventh  cervical  and  mastoid  points  forming  a  straight  line  above  it. 
There  is  generally  lordosis,  the  pelvis  is  near  the  perpendicular,  and  the 
body  axis  lies,  as  a  rule,  behind  the  perpendicular.  The  legs  are  rather 
vertical,  and  if  there  is  not  marked  lordosis,  the  knees  are  apt  to  be  hy- 
perextended. This  type  is  second  in  frequency,  and  represents  the 
seventh  dorsal  point  as  the  most  prominent  point  backward,  with  some 
lordosis  in  the  lumbar  region  (Fig.  146). 

Type  C. — The  lower  part  of  the  back  is  straight,  and  the  head  runs 
forward  from  the  seventh  cervical.  There  is  generally  not  much  lor- 
dosis, the  pelvis  is  not  pushed  forward,  but  is  near  the  perpendicular, 
and  the  body  axis  lies  back,  as  a  rule.  The  knees  may  or  may  not  be 
hyperextended.  In  this  case  the  head  is  thrust  forward  from  the  upper 
part  of  the  spine,  and  the  body  weight  is  thrown  back  (Fig.  147). 

Type  D. — The  spinal  points  form  a  line  nearly  or  cjuite  straight. 


174  FAULTY   ATTITUDE. 

The  back  is  nearly  flat,  lordosis  is  marked,  the  pelvis  is  generally  back, 
but  it  may  be  forward,  and  the  knees  generally  somewhat  flexed. 

It  is  of  interest  to  inquire  what  relation  these  types  bear  to  the  types 
formulated  by  Staflel.  Points  were  marked  on  his  figures  correspond- 
ing to  the  bony  landmarks  selected,  lines  drawn,  and  a  perpendicular 
erected  through  the  external  malleolus.  Group  A  in  this  classification 
corresponds  to  his  "round  back";  Group  B  is  his  "round  hollow 
back  " ;  Group  C  is  his  "  hollow  back  " ;  and  Group  D  is  his  "  flat  back. " 
The  difference  between  Groups  C  and  D  in  his  classification  is  not  so 
distinct  as  in  these  cases. 

The  flat  hack  is  to  be  considered  rather  a  peculiarity  of  conforma- 
tion than  a  deformity  requiring  attention.  It  is  significant  largely  from 
the  fact  that  such  children  are  particularly  likely  to  develop  scoliosis. 

The  hollow  back  within  moderate  limits  is  in  the  same  way  to  be  re- 
garded as  a  peculiarity  of  conformation.  The  hollow  back  or  lordosis, 
however,  may  reach  a  high  degree  in  certain  pathological  conditions. 
The  least  abnormal  pathological  deviation  in  lordosis  is  found  in  the 
marked  hollow  back  of  backward  contortionists.  Lordosis  occurs 
pathologically  in  connection  with  pregnancy,  in  paralysis  of  abdominal 
or  back  muscles,  in  tuberculous  disease  of  the  lumbar  spine,  in  severe 
rickets,  in  double  congenital  dislocation  of  the  hip,  in  double  coxa  vara, 
in  ankylosis  of  the  hip  in  a  flexed  position  from  tuberculous  disease 
or  other  cause,  and  in  spondylolisthesis. 


ROUND  SHOULDERS. 

Stoop  or  slant  shoulders,  round  back,  round  hollow  back,  stooping, 
faulty  attitude,  kyphosis,  bowed  back. 

German — Schlechte  Haltung,  runde  Riicken,  Kyphose,  hohhrunde 
Rucken,  Kypholordose,  habituelle  Kyphose. 

French — Dos  Voute,  Cyphose, 

Italian — Schiene  rotonde. 

Grouped  under  this  name  are  various  types  of  faulty  attitude.  Va- 
riations from  the  normal  attitude  in  the  lateral  plane  of  the  body  have 
been  discussed  under  scoliosis.  Variations  in  the  anteroposterior  plane 
will  now  be  taken  up.  When  the  two  variations  coexist,  as  frequently 
happens,  the  lateral  variation  is  in  general  considered  the  important 
one,  and  the  case  is  classed  as  scoliosis.  Variations  from  the  normal 
anteroposterior  attitude  are  in  general  grouped  under  the  name  of 
round  shoulders,  shading  into  each  other  and  characterized  by  a  dispo- 
sition to  economize  muscular  force  in  maintaining  the  erect  position. 


ROUND   SHOULDERS.  17,5 

These  deviations  have  been  but  imperfectly  studied  or  formulated,  and 
have  in  general  been  grouped  as  round  shoulders  because  an  increased 
convexity  of  the  dorsal  spine  is  the  most  common  characteristic. 

In  general  the  attitude  is  familiar,  the  head  is  carried  forward  and  is 
somewhat  flexed,  the  physiological  curve  in  the  dorsal  region  is  increased 
and  the  dorsal  region  unduly  prominent  behind,  in  which  backward 
curve  the  lumbar  region  may  share,  or  there  may  be  also  an  increased 
lumbar  curve  forward.  The  shoulders  are  drooping  and  the  chest 
narrow  and  fiat,  while  the  scapulae  behind  are  prominent  on  their  pos- 
terior borders  and  the  inferior  angles  may  stick  out  markedly  (scapulas 
alatse).  The  abdomen  is  prominent  and  the  pelvic  inclination  varies. 
Flat-foot  or  pronated  foot  frequently  coexists. 

Children  with  round  shoulders  are,  as  a  rule,  below  the  average  in 
muscular  development  and  lack  vigor ;  they  are  clumsy  in  their  movements 
and  walk  heavily.  In  some  cases  the  deformity  can  be  removed  by  a 
muscular  effort  on  the  part  of  the  patient  or  by  gentle  pressure  with  the 
hands,  but  in  most  cases  of  even  average  severity  the  deformity  cannot 
be  wholly  corrected  by  gentle  passive  force,  as  the  maintenance  of  the 
malposition  has  led  to  adaptive  shortening  of  the  soft  parts  concerned. 
The  cases  may  therefore  be  considered  as  flexible  or  resistant,  an  impor- 
tant distinction  in  treatment.  Great  injustice  is  done  to  children  with 
resistant  round  shoulders  by  the  continual  commands  to  "sit  straight," 
a  position  which  it  is  impossible  for  them  to  assume. 

If  such  a  child  is  laid  face  downward  on  a  table  with  the  arms  at 
right  angles  to  the  body  the  arms  may  by  passive  force  be  carried  back 
of  the  middle  line  of  the  body.  If  in  this  position  the  arms  are  carried 
up  beside  the  head  and  then  lifted  back  they  cannot  as  a  rule  be  carried 
so  far  as  the  median  plane  of  the  body.  If  such  a  child  is  told  to  put 
the  arms  up  in  the  air  in  the  standing  position  it  is  done  by  making  the 
back  hollow  in  the  lower  part  and  protruding  the  abdomen,  because  the 
soft  parts  between  the  chest  and  arms  do  not  permit  a  free  movement.^ 
Lateral  curvature  of  the  spine  coexists  in  the  majority  of  cases  of  this 
sort. 

The  affection  is  not  wholly  one  of  the  spine,  but  implies  a  disturb- 
ance of  relations  from  the  feet  upward  because  an  increase  in  the 
backward  curve  of  the  spine  implies  a  forward  curve  or  forward  dis- 
placement somewhere  else  to  balance  it.  The  dorsal  spine  in  other 
words  cannot  become  more  convex  without  a  compensating  lumbar 
curve  forward,  or  a  forward  displacement  of  the  pelvis  and  legs  if  the 
lumbar  spine  is  involved  in  the  backward  dorsal  curve. 

'  E.  H.  Bradford:   "Round  Shoulders,"  "Orth.  Trans.,"  vol.  x,  page  162. 


176 


FAULTY    ATTITUDE. 


Round  shoulders,  therefore,  is  not  to  be  considered  or  treated  as 
an  affair  wholly  concerning  the  dorsal  spine  and  shoulders.  On  closer 
analysis  these  cases  will  be  found  to  fall  into  three  not  very  well-defined 
groups.  Transition  cases  of  all  grades  are  seen,  and  the  division  is 
mentioned  simply  to  aid  in  the  study  of  the  cases  and  their  treatment. 
The  groups  are  as  follows : 

I.  ROUND  BACK. 

The  dorsal  and  lumbar  spine  form,  one  convexity  backward,  which 

is  physiologically  a  persistence  of  the  infantile  position.     A  lordosis 

is  apparently  often  present,  but  on  identifying  the  landmarks  this  will 

be  found  to  be  merely  the  upward  and  forward  slope  of  the  sacrum 


Fig.  149.— Round  Back. 


and  that  the  lumbar  spine  does  not  share  in  it.  A  plumb-line  dropped 
through  the  mediotarsal  joint  passes  behind  the  ear  and  the  hip-joint, 
but  most  of  the  dorsal  curve  is  behind  it.  The  pelvic  inclination  is 
diminished.  This  corresponds  to  T^-pe  A  of  the  classification  given 
above  and  to  the  round  back  of  Staft'el  and  Combe. 


ROUND    SHOULDERS. 


177 


2.  ROUND  HOLLOW  BACK. 
The  dorsal  spine  is  bowed  backward,  but  the  himbar  spine  is  bowed 
forward.  The  appearance  of  round  shoulders  is  present,  bvit  the  general 
attitude  is  modified  because  the  pelvis  has  a  greater  inclination  than 
in  round  back  and  is  not  so  far  forward,  the  abdomen  is  prominent, 
and  the  gross  appearance  is  the" same  as  in  round  back — the  essential 
modification  being  produced  by  the  greater  pelvic  inclination.     This 

corresponds  to  Type  B  of  the 
classification  given  above,  to  the 
round  hollow  back  of  Staft'el,  and 
the  kypholordosis  of  Combe. 


Fig.  150.— Round  Hollow  Back. 


Fig.  151.— Forward  Position  of  the 
Shoulder-girdle. 


3.  FORWARD  DISPLACEMENT  OF  THE  SHOULDERS. 
A  condition  has  been  described  by  Hasebrook  ^  in  which  a  forward 
displacement   of   scapulae   and   shoulders    is    the   chief   characteristic. 
'  "Zeitsch.  f.  orth.  Chir.,"  .xii,  4,  613. 


lyS  FAULTY   ATTITUDE. 

This  displacement  may  exist  with  a  fiat  back,  in  which  case  it  is  quite 
unlike  ordinary  round  shoulders,  or  it  may  exist  in  connection  with 
a  rounded  back,  in  which  case  it  is  not  conspicuously  different  from 
the  types  described.  The  displacement  may  be  flexible  or  resistant 
to  correction  by  passive  force.  For  purposes  of  clearness  the  name 
round  shoulders  will  be  used  to  designate  the  three  groups. 

ETIOLOGY. 
In  general  the  causes  of  round  shoulders  are  to  be  sought  in — (a) 
conditions  causing  muscular  weakness;  (b)  conditions  causing  a  flexed 
position  of  the  lumbar  spine  for  long  periods,  and  in  (c)  overweighting 
of  the  shoulders  by  improperly  arranged  clothing.  Hoffa  inclines 
toward  the  view  that  a  weakness  of  the  will  is  a  more  important  cause 
than  weakness  of  the  muscles. 

a.  Conditions  causing  muscular  weakness  are  found  in  rapid  growth, 
overwork  and  bad  air  at  school,  improper  school  furniture,  acute  illness, 
bad  hygiene  at  home,  and  similar  conditions. 

b.  Prolonged  flexion  of  the  spine  is  induced  by  school  furniture 
which  fails  to  support  the  back,  by  errors  in  vision  which  necessitate 
stooping  over  the  books  in  reading,  and  in  careless  attitudes  of  reading 
and  sitting  permitted  at  home.  The  child  with  normal  eyes  should  not 
have  to  hold  the  book  nearer  than  twelve  to  fourteen  inches. 

c.  The  customary  method  of  supporting  a  child's  clothes  in  this 
community  consists  in  the  use  of  a  waist,  loose  around  the  abdomen, 
to  which  drawers  and  skirts  or  trousers  are  buttoned.^  To  this  waist 
are  also  attached  side  elastic  stocking  supporters  which  are  kept  tight 
to  prevent  the  stockings  from  wrinkling.  This  waist  is  supported  above 
by,  two  shoulder-straps  passing  over  the  shoulders  near  their  tips. 
The  whole  weight  of  the  clothes  and  the  added  pull  of  stout  elastics 
is  thus  transferred  to  the  child's  movable  shoulders,  of  all  parts  of  the 
body  the  least  suited  to  hold  against  a  steady  downward  pull.  This 
pull  is  transferred  in  a  measure  to  the  spine  by  the  muscles,  clavicles, 
and  thorax,  and  tends  to  produce  flexion. 

The  remedy  of  this  condition  consists  in  supporting  as  much  as 
possible  the  clothing  from  a  belt,  in  using  round  garters,  and  in  having 
a  waist  ,made  in  which  the.  pull  comes  at  the  root  of  the  neck  instead  of 
at  the  tips  of  the  shoulders. 

^Bradford:  "Orth.  Trans.,"  vol.  x,  162;  Goldthwait:  "Amer.  Jour,  of  Orth. 
Surg.,"  vol.  i,  64. 


ROUND    SHOULDEKS.  1 79 

OCCURRENCE. 
Scholder  found  5.8  per  cent,  of  round  backs  in  the  school  children 
of  Lausanne,  about  equally  divided  between  boys  and  girls,  the  per- 
centage of  scoliosis  in  these  children  being  above  25.  The  age  of  occur- 
rence of  round  shoulders  covers  the  period  of  childhood  from  shortly 
after  the  time  that  walking  begins  to  adolescence;  most  cases  are  seen 
by  the  surgeon  in  middle  childhood  and  about  puberty,  when  in  girls 
especial  attention  is  paid  to  the  figure  and  carriage. 

PATHOLOGY  AND  MECHANISM. 

The  pathological  changes  in  round  shoulders  must  be  determined 
rather  by  inference  and  interpretation  of  clinical  symptoms  than  by 
postmortem  examination. 

Permanent  kyphosis  in  a  healthy  growing  dog  was  produced  ex- 
perimentally by  WuUstein,  who  approximated  the  pelvis  and  shoulders 
by  straps,  causing  a  flexed  position  of  the  spine.  In  children  who 
continue  to  grow  with  the  spine  in  flexion  analogous  adaptive  changes 
must  occur  in  the  spine  and  its  surrounding  structures  to  those  found 
in  scoliosis.  Fitz,  in  a  series  of  dissections  on  about  one  hundred 
normal  cadavers,  supplemented  by  clinical  observation  on  fifty-six 
children  with  round  shoulders,  concluded  that  in  resistant  round  shoul- 
ders the  obstacle  to  reposition  was  not  to  be  found  in  the  pectoral  muscles, 
but  that  the  most  common  factor  was  tightness  of  the  serratus  muscle. 
Occasionally  associated  with  this  was  to  be  found  shortness  of  the 
coracoclavicular  and  acromioclavicular  ligaments.^ 

Hasebrook^  considered  the  cause  of  resistant  forward  displacement 
of  the  shoulders  to  lie  partly  in  the  costoclavicular  and  coracoclavicular 
ligaments  and  partly  in  the  pectoralis  and  serratus  muscles.  He 
divided  the  cases  into  two  groups — first,  those  due  to  contraction  of  the 
muscles  holding  the  shoulders  forward,  and,  second,  to  weakness  of  the 
muscles  holding  them  back. 

PROGNOSIS. 
The  attitude  of  round  shoulders  is  not  to  be  regarded  as  one 
which  will  be  spontaneously  outgrown.  On  the  other  hand,  it  requires 
treatment,  and  with  adequate  treatment  and  proper  hygiene  the  prog- 
nosis for  recovery  is  good  in  young  children.  In  older  children  and 
adolescents  improvement  and  perhaps  cure  are  to  be  obtained.     Even 

^  G.  W.  Fitz:   "Bos.  Med.  and  Surg.  Jour.,"  Apr.  19,  1906. 
^"Zeitsch.  f.  orth.  Chir.,"  xii,  4,  613. 


ISO  FAULTY   ATTITUDE. 

in  young  adults  an  improved  position  of  the  shoulders  and  a  better  ex- 
pansion of  the  chest  are  to  be  secured  by  adequate  treatment. 

DIAGNOSIS. 

The  diagnosis  of  round  shoulders,  as  a  rule,  presents  no  difiB.culty, 
but  at  times  it  is  not  easily  distinguished  from  more  serious  affections, 
causing  a  backward  bowing  of  the  spine.  The  means  of  distinguish- 
ing between  the  different  varieties  of  round  shoulders  have  been  sufl&- 
ciently  indicated  in  the  description  of  them.  The  most  important 
point  is  to  distinguish  a  static  bowing  of  the  spine  from  one  caused 
by  disease.  In  the  former  there  is  no  marked  stiffness  of  the  spine, 
pain  is  absent,  the  bowing  is  gradual,  and  x-ray  appearances  are  normal. 

Differential  Diagnosis. — PoWs  disease  (tuberculosis  of  the  spine, 
angular  cur\'ature  of  the  spine)  is  discussed  in  speaking  of  the  diagnosis 
of  scoliosis.  At  certain  stages  of  dorsal  Pott's  disease  the  attitude 
may  resemble  round  shoulders. 

Arthritis  deformans  of  the  spine  is  discussed  under  the  diagnosis 
of  scoliosis. 

The  neurasthenic  spine  (hysterical  spine,  irritable  spine)  exists 
both  by  itself  and  as  a  complication  of  round  shoulders  in  persons  of  a 
nervous  temperament.  It  affects  generally  female  adults,  but  may 
occasionally  be  seen  in  children,  generally  in  girls  approaching  puberty. 
The  back  is  painful  and  perhaps  somewhat  stiff  on  motion,  the  skin 
is  sensitive,  and  symptoms  of  irritability  are  acute.  The  x-ray  appear- 
ances are  normal.  Such  irritable  spines  may  follow  accidents,  strains, 
and  overuse. 

No  gymnastic  treatment  for  a  case  of  round  shoulders  should  be 
undertaken  in  a  patient  where  pain  or  stiffness  /^f  the  back  is  present 
v^ithout  a  very  careful  preliminary  period  of  observation  and  a  careful 
elimination  of  the  first  two  conditions  mentioned  above. 

TREATMENT. 

The  treatment  of  round  shoulders  is  different  in  flexible  or  non- 
resistant  cases  and  in  resistant  cases. 

Non-resistant  Round  Shoulders  (Flexible  Round  Shoulders).— 
The  treatment  does  not  differ  radically  from  that  of  postural  scoliosis 
in  that  both  are  of  the  type  of  the  "setting-up  drill"  of  the  army  recruit. 
In  both  one  tries  to  substitute  a  correct  attitude  for  the  incorrect  or 
faulty  one.  What  has  been  said  with  regard  to  the  treatment  of  postural 
or  functional  scoliosis  applies  equally  to  the  treatment  of  flexible  round 
shoulders,  the  routine  and  exercises  being  described  in  that  place  (page 


TREATMENT  OF  ROUND  SHOULDERS.  l8l 

124)  for  both  conditions,  and  certain  exercises  being  designated  as 
especially  adapted  to  round  shoulders. 

Resistant  Round  Shoulders. — The  treatment  of  these  cases 
is  similar  in  plan  to  that  of  structural  scoliosis  where  first  mobilizing 
and  then  retentive  measures  must  be  separately  recognized,  even  if 
both  are  carried  out  simultaneously. 

Mobilization. — When  the  shoulders  are  held  forward  by  contrac- 
tion of  the  soft  parts  and  cannot  easily  be  replaced  in  the  normal  position, 
simple  gymnastics  are  likely  to  prove  unsatisfactory  and  some  stretch- 
ing of  the  contracted  parts  is  necessary  in  order  to  save  time  and  make 
gymnastics  more  effective.  To  stretch  these  soft  parts  by  gymnastic 
exercises  is  slow  and  often  unsatisfactory,  and  when  it  is  done  must 
be  accomplished  by  passive  stretching  induced  by  pulling  back  the 
shoulders  either  with  the  arms  at  the  sides  or  on  a  level  with  the  shoulders, 
whichever  position  offers  the  greatest  resistance. 

Passive  stretching,  however,  by  means  of  an  apparatus  is  more 
efficient  and  quicker.  The  means  to  be  described  offers  a  simple 
method. 

The  apparatus  consists  of  an  oblong  gas-pipe  frame  of  the  ordinary  pattern. 
Fastened  to  this  near  the  middle,  and  hinged  so  as  to  be  raised  to  any  degree,  is 
another  section  of  gas-pipe  lying  on  the  frame  proper  and  of  the  same  shape  and 
size  as  the  upper  half  of  the  frame.  To  this  movable  section  is  fastened,  at  right 
angles  to  it  and  movable  on  it,  a  gas-pipe  bridge  rising  about  eighteen  inches  from 
the  movable  section  (Fig.  152). 

When  prepared  for  use  two  strips  of  webbing,  lying  one  over  the  other,  run 
from  each  of  the  buckles  at  the  bottom  of  the  frame.  The  lower  two  strips  are 
tightly  drawn,  and  run  to  the  buckles  at  the  end  of  the  movable  section.  The 
upper  two  are  loosely  fastened  to  the  bridge  over  the  movable  section.  The  cross- 
pieces  are  tightened  and  the  patient  laid  face  downward  on  the  webbing  strips, 
which  may,  if  desired,  have  laid  over  them  a  folded  piece  of  sheet  wadding.  The 
strips,  however,  even  in  adults,  are  not  uncomfortable.  The  thighs  are  flexed 
and  the  feet  rest  on  the  floor,  so  that  the  lumbar  spine  is  flattened.  Two  pieces 
of  webbing  are  passed  over  the  middorsal  region  from  side  to  side,  tied  to  the  lower 
non-movable  frame  on  each  side.  These  furnish  the  resistance  for  the  straighten- 
ing of  the  spine  when  the  upper  end  of  the  frame  is  lifted,  carrying  with  it  the  head 
and  upper  chest.  The  upper  part  of  the  frame  is  lifted  after  the  patient  is  in  place 
and  as  much  force  as  seems  advisable  is  exerted.  This  should  never  be  pushed 
beyond  the  point  of  mild  discomfort.  Several  stretchings  are  first  made  of  a  few 
seconds  each,  and  the  movable  part  of  the  frame  again  let  down  to  rest  the  patient. 

Forcible  Correction. — In  average  cases  intermittent  stretching  is 
suf&cient  to  loosen  up  the  contraction  and  to  make  an  improved  po- 
sition possible.  In  the  severer  cases,  however,  a  plaster  jacket  should 
be  applied  in  the  improved  position. 


l82 


FAULTY   ATTITUDE. 


The  patient's  spine  is  hyperextended  as  described,  by  raising  the 
movable  part  of  the  frame,  which  is  then  fastened  in  this  position  and 
a  plaster-of-Paris  jacket  applied,  including  the  shoulders,  which  must 
be  well  padded  by  felt  on  their  anterior  surface.  This  jacket  holds  the 
dorsal  spine  somewhat  extended,^  and  the  shoulders  back  by  firm 
pressure,  and  the  pressure  can  be  increased  from  day  to  day  by  insert- 
ing more  felt  between  the  jacket  and  the  shoulders. 


Fig.  152. — Apparatus  for  Stretching  Round  Shoulders  and  for  the  Application  of 

Forcible  Jackets. 


Such  jackets  should  be  worn  from  two  to  four  weeks,  and  on  their 
removal  efficient  gymnastic  work  begun,  supplemented  by  braces,  if 
necessary,  to  hold  the  improved  position  bet^-een  treatments. 

Braces. — ^The  use  of  supports  to  maintain  the  spine  in  a  correct 
position  is  indicated — (i)  in  the  case  of  children  with  lax  muscles  who 
are  unable  to  hold  an  erect  position  betv\'een  gymnastic  treatments; 
(2)  after  forcible  correction  to  retain  what  has  been  gained,  and  (3) 
in  resistant  cases  which  are  being  stretched  but  which  cannot  maintain 

^  R.  W.  Lovett:  "  Amer.  Jour,  of  Orth.  Sur., "  ii,  2,  200. 


TREATMENT  OF  ROUND  SHOULDERS. 


183 


between  stretchings  the  improvement  secured  by  each  one.  In  all 
of  these  the  brace  is  to  be  regarded  as  a  temporary  measure  supple- 
mentary to  the  other  treatment,  whether  gymnastic  or  mobilizing,  and  to 
be  given  up  as  soon  as  it  can  be  dispensed  with.  As  the  sole  treat- 
ment of  resistant  round  shoulders  the  use  of  a  brace,  which  by  its  correc- 


FiG.  153. — Round  Shoulders  befork 
Forcible  Correction. 


Fig.  154. — Round  Shoulders  after 
Treatment  Following  Forci- 
ble Correction. 


tive  effect  is  to  cure  the  malposition,  is  not  to  be  advised.  The  use  of 
modified  suspenders,  known  as  "shoulder  braces,"  as  sold  in  the  instru- 
ment shops,  is  not  satisfactory.  The  brace  which,  on  the  whole,  is  the 
most  generally  effective  is  the  tempered  steel  upright  support.  It 
is  made  as  follows : 

This  form  of  apparatus  consists  of  (a)  a  horizontal  pelvic  band,  (b)  two  upr 
rights,  and  (c)  a  cross-bar. 


184  FAULTY   ATTITUDE. 

a.  The  horizontal  pelvic  band  encircles  the  posterior  part  of  the  pelvis  from 
a  point  one  inch  posterior  to  the  anterior  superior  spine  on  one  side  to  a  similar 
point  on  the  other  side.  It  is  curved  to  fit  the  contour  of  the  pelvis  and  should 
lie  close  against  it.  It  is  made  of  No.  15  gauge  sheet  steel,  one  and  one-eighth 
inches  wide.  The  uprights  run  from  the  posterior  pelvic  band  along  the  sides 
of  the  spine  to  a  point  about  on  a  level  with  the  acromion  process.  At  this  point 
they  are  curved  outward  on  the  flat  on  an  angular  turn  at  an  angle  of  forty-five 
degrees  or  more,  and  run  upward  and  outward  to  a  point  just  behind  the  anterior 
border  of  the  trapezius.  In  their  upper  part  they  are  curved  to  fit  the  contour  of 
the  shoulders  and  should  lie  flat  against  the  skin  when  the  axillary  straps  are  tight- 
ened. 

b.  The  uprights  at  their  lower  part  are  farther  from  each  other  than  they  are 
at  the  top.  At  the  bottom  their  outer  edges  should  be  separated  by  a  distance 
somewhat  less  than  the  distance  between  the  two  posterior  superior  spines.  At 
the  top  they  should  lie  over  the  transverse  processes.  They  are  made  of  No.  16 
gage  sheet  steel,  five-eighths  of  an  inch  wide,  and  should  foUow  the  outline  of  the 
back  in  general,  but  whatever  correction  is  desired  in  the  standing  position  is  to 
be  made  by  bending  the  uprights  to  fit  the  cmtwq  of  the  back  in  a  corrected  posi- 
tion rather  than  in  the  faulty  position. 

c.  The  cross-bar  consists  of  a  piece  of  steel,  which  in  length  should  be  one 
inch  less  on  each  side  than  the  breadth  of  the  body  at  the  level  where  it  is  placed. 
It  is  riveted  transversely  to  the  uprights  at  a  point  just  below  the  posterior  fold 
of  the  axilla.  The  projecting  ends  beyond  the  bars  should  not  rest  on  the  scapulae, 
but,  if  necessary,  should  be  set  backward  by  an  angular  curve  to  clear  the  scapulae. 
These  are  made  of  the  same  material  as  the  uprights. 

Holes  are  drilled  for  buckles  at  each  anterior  end  of  the  pelvic  band,  at  the 
top  of  the  uprights,  and  at  the  ends  of  the  cross-bar.  Buckles  are  placed  on 
the  ends  of  the  pelvic  band,  and  the  cross-bar  and  axillary  straps  are  riveted  to 
the  upper  ends  of  the  uprights,  one  on  each  side.  The  brace  is  finished  by  being 
covered  with  leather  sewed  down  the  back  throughout,  or  by  being  nickel-plated 
and  having  its  anterior  surface  only  covered  with  padded  leather  strips  slightly 
wider  than  the  metal  parts  of  the  brace.  These  are  attached  to  the  brace  by 
loops  running  around  the  uprights,  pelvic  band,  and  the  cross-bar.  The  brace 
is  attached  to  the  body  at  the  top  by  means  of  axillary' straps  and  below  by  means 
of  a  broad  belt  of  sheep-skin  or  surcingle  cloth,  which  connects  the  anterior  ends  of 
the  pelvic  band  by  passing  over  the  lower  part  of  the  abdomen.  In  cases  in  which 
there  is  much  prominence  of  the  abdomen,  it  is  desirable  to  add  an  abdominal 
band,  from  four  to  six  inches  wide,  running  from  one  upright  around  the  abdomen 
to  the  other  upright. 

Such  a  brace  is  worn  continuously  between  exercise  periods  but  not 
during  the  night. 

A  brace  used  by  the  writer  in  cases  where  forward  displacement 
of  the  shoulders  is  a  factor  consists  of  two  parts — (a)  an  anterior  chest 
piece ;  {h)  two  triangular  steel  plates  to  be  used  posteriorly,  one  on  each 
side,  (a)  The  chest  piece  consists  of  two  slightly  oval  pads  of  sheet 
steel  about  the  size  of  a  silver  dollar,  which  fit  over  the  anterior  surfaces 


TREATMENT    OF   ROUND    SHOULDERS.  185 

of  the  shoulder-joints  and  are  connected  by  a  flat  iron  strip  of  the 
proper  length,  curved  so  as  not  to  touch  the  chest.  Each  pad  is  pro- 
vided with  a  vertical  piece  of  steel  about  three  inches  long,  on  the  top 
and  bottom  of  which  is  a  buckle,  (b)  Two  triangular  flat  steel  plates, 
about  half  the  size  of  the  scapula  of  the  child,  are  made  of  sheet  steel 
and  provided  each  with  three  buckles.  One  of  these  lies  over  each 
scapula.  The  front  piece  holds  the  shoulders  back,  and  each  end  is 
secured  to  the  triangular  plate  on  that  side  behind  by  one  strap  passing 
over  the  shoulder  and  one  through  the  axilla.  The  front  piece  being 
fastened  to  each  of  the  triangular  plates,  the  latter  are  brought  together 
by  a  webbing  strap  connecting  them  until  an  efficient  pull  is  secvu-ed. 
A  webbing  support  which  is  of  use  in  the  slighter  cases  has  been  described 
by  Goldthwait.^ 

"Occasionally,  when  the  stoop  shoulder  is  marked,  some  additional  support 
may  be  necessary,  and  with  many  of  the  cases  it  has  been  possible  to  accomplish 
the  result  by  using  a  brace  made  of  firm  webbing  one  inch  wide,  carried  as  a  loop 
around  each  shoulder,  the  ends  crossing  in  the  back,  and  being  attached  to  the  belt 
of  an  ordinary  stocking  supporter.  The  attachment  of  the  shoulder  strap  to  the  belt 
should  be  at  the  side,  directly  over  the  stocking  straps,  and  the  belt  should  be  worn 
about  the  hips,  and  not  about  the  waist,  as  they  are  ordinarily  used.  The  straps 
should  be  sewed  where  they  cross  at  the  back,  over  the  angles  of  the  scapulas,  but 
should  not  be  sewed  where  they  cr6ss  in  the  midline.  This  allows  all  the  body 
movements,  both  side  and  forward  bendings,  without  straining  upon  the  straps  or 
changing  the  position  of  the  belt,  the  level  of  the  belt  not  being  changed  in  the 
movement. 

"  It  is  at  once  apparent  that  with  such  a  brace  the  pull  occasioned  by  the  stock- 
ing supporters,  which  is  a  very  appreciable  force,  tends  constantly  to  draw  the 
shoulders  backward;  and,  while  so  simple  a  brace  cannot  be  expected  to  take 
the  place  of  the  many  forms  of  apparatus  which  are  used  to  correct  round  shoulders, 
it  has,  nevertheless,  been  of  real  value  in  many  cases." 

Summary  of  the  Treatm.ent  of  Round  Shoulders. — Flexible  cases  are 
treated  by  gymnastics  like  postural  scoliosis ;  a  brace  may  be  necessary 
to  mairttain  a  correct  position  between  treatments. 

Resistant  cases  must  first  be  made  flexible — (a)  by  gymnastics;  {b) 
by  manual  stretching ;  {c)  by  stretching  in  apparatus ;  {d)  by  forcible 
correction,  after  which  the  problem  is  to  maintain  the  improved  position, 
just  as  in  cases  originally  flexible. 

'  "Am.  Jour.  Orth.  Surg.,"  i,  64. 


INDEX. 


Acquired  scoliosis,  94 
Age  in  scoliosis,  no 
Asymmetrical  exercises,  137 
Asymmetry  of  the  pelvis,  95 
Attitude,  167 

faulty,  167 

normal,  167 

B. 

Balance  of  spine,  39 
Braces  and  corsets,  163 

C. 

Cervico-dorsal  scoliosis,  60 
Compound  curves,  61 
Congenital  scoliosis,  92 
Creeping  exercises,  142 

D. 

Diagnosis  of  scoliosis,  113 
Dorsal  scoliosis,  58 
Dorso-lumbar  scoliosis,  59 

E. 

Elasticity  of  spine,  38 
Errors  in  vision,  97 
Etiology,  91 

Examination  for  scoliosis,  64 
Exercises,  asymmetrical,  137 

creeping,  142 

symmetrical,  127 

F. 

Faulty  attitude,  167 

Forcible  correction,  148 

Forvsrard  displacement  of  the  shoulders, 

177 
Frequency  of  different  forms,  in 
Functional  scoliosis,  48 


H. 


G)Tnnastics,  120 


G. 


Habit  scoliosis,  10 1 


Intervertebral  discs,  3 

J- 
Joint  disease  as  a  cause  of  scoliosis. 


Ligaments  of  the  spine,  5 
Lumbar  scoliosis,  56 

M. 

Mechanism  of  scoliosis,  38 
Movements  of  the  spine,  23 
Muscles  of  the  spine,  9 

N. 

Normal  attitude,  167 
Numerical  variation,  19 

O. 

Occupation  scoliosis,  loi 
Occurrence  of  scoliosis,  108 
Operative  treatment,  165 


Paralytic  scoliosis,  99 
Passive  stretching  of  the  spine,  144 
Pathology  of  scoliosis,  77 
Pelvic  inclination,  17 
Physiological  curves,  14 
Plaster-of -Paris  jackets,  148 
Plasticity  of  bone,  41 
Postural  scoliosis,  48 
Prognosis  of  scoliosis,  116 

R. 

Rachitic  scoliosis,  97 
Rate  of  normal  growth,  64 


187 


INDEX. 


Record  of  scoliosis,  71 
Round  back,  176 

hollow  back,  177 

shoulders,  174 
treatment  of,  180 


Sacro-iliac  articulation,  6 

School  conditions,  influence  of,  91 

fatigue,  102 

furniture,  103 
Scoliosis,  acquired,  94 

age  in,  no 

cervico-dorsal,  60 

congenital,  92 

diagnosis  of,  113 

dorsal,  58 

dorso-lumbar,  59 

examination  for,  64 

functional,  48 

habit,  loi 

joint  disease  as  a  cause  of,  98 

lumbar,  56 

mechanism  of,  38 

occupation,  loi 

occurrence  of,  108 

paralytic,  99 

pathology  of,  77 

postural,  48 

prognosis  of,  116 

rachitic,  97 

record  of,  71 

sex  in,  109 

structural,  56 


Scoliosis,  symptomatic,  115 

terminology  of,  47 

transitional,  52 

treatment  of  postural,  118 
of  structural,  119 
Sex  in  scoliosis,  109 
Short  leg,  95 
Spinal  iierves,  11 
Spine,  balance  of,  39 

elasticity  of,  38 

ligaments  of  the,  5 

movements  of  the,  23 

muscles  of  the,  9 

passive  stretching  of  the,  144 
Structural  scoliosis,  56 
Symmetrical  exercises,  127 
Symptomatic  scoliosis,  115 
Surface  anatomy,  21 


Terminolog}^  of  scoliosis,  47 
Thorax,  6 
Torticollis,  95 
Transitional  scoliosis,  52 
Treatment  of  postural  scoliosis, 
of  structural  scoliosis,  119 


V. 

Variations  in  height,  38 

W. 
Writing  position,  106 


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